Welcome to University Hospitals Coventry & Warwickshire NHS
Trust’s (UHCW NHS Trust) third Annual Quality Account. I hope you
find it useful in showing how we performed in 2011/12 and what our
priorities are for the next 12 months. Our mission is to Care, Achieve
and Innovate by:
• delivering safe, high quality and evidence based patient care
• developing excellence in research and education
• enhancing efficiency and promoting our high quality service locally
and nationally.
The three priorities we focused on last year were picked because we
knew it would make a big difference to the experience of the majority
of our patients: the management of sepsis, looking after patients’
nutritional needs and improving care for patients with dementia.
I am proud of the work we have undertaken in these areas which are
discussed in more detail in this Quality Account, but includes an
awareness and training campaign for staff on sepsis, the appointment
of a consultant to strengthen the Nutrition Support Team and the opening of our Memory Lane and
Forget-me-not Lounge for patients with dementia.
We have also strengthened our Patient Engagement team to focus on the experience of patients
and their loved ones. Our engagement team as well as being led by a director and incorporating
Patient Involvement, PALS and Complaints, also includes Bereavement Services and the
department of Spiritual Care. This is because we recognise that having a relative in hospital usually
impacts on the family around them and they may also require support.
The Patient Experience and Engagement Group have now been established for more than a year
and discuss projects which enhance not only patients’ experience but the environment in which they
are treated. For example in the last 12 months this has included improving the information on
outpatient letters, installing benches so patients and visitors can sit outside and launching a pilot on
the information on ward notice boards. Two members of the Trust Board (an executive and nonexecutive member) sit on this group and the minutes from the meetings are also shared with the
Trust Board. Trust Board members also take part in Patient Safety Walkarounds where they will visit
wards unannounced to see the quality of care being provided and Patient Stories are given to the
Trust Board so the Executive Team can hear firsthand about the experiences of their patients.
As well as monitoring the opinions of our local community through social media and local media
outlets, we also have a Patients Council, 5,000 public Foundation Trust members and a number of
schools which we communicate with regularly as well as our local MPs, LINks and Health and
Overview Scrutiny Committees. As a result to listening to our patients, visitors and local
communities we reduced car parking prices at University Hospital from July 1, 2011 and have also
begun work focusing on congestion at the same site as we know this is an issue which causes
stress to all involved.
All patients and visitors are encouraged to take part in the Trust Impressions survey which allows
them to give feedback broken down to ward level. This is shared with ward management to allow

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them to act on all comments they receive, whether it is positive or negative. Currently we receive
approximately 1,000 responses a month to our survey and this means when Midlands and East
Strategic Health Authority (MESHA) asked acute Trusts to start asking their inpatients whether they
would recommend their hospital from April 2012, the Trust was already one step ahead.
The Trust is also proud to be an early user of the NHS Patient Safety Thermometer and is one of the
few acute Trusts working directly with MESHA to achieve its aim to eliminate avoidable grade 2, 3
and 4 pressure ulcers by December 2012.
In addition to all this work, during 2011/12 many staff have been nominated for various prestigious
awards:
• Consultant Ophthalmologist Sergio Pagliarini was shortlisted for one of The Macular Disease
Society’s 2011 national awards for Clinical Services of the Year after being nominated by a
patient.
• The Research and Development team was shortlisted for the HSJ Awards 2011 for
embedding a culture of clinical research at Trust level.
• The cross-disciplinary team who managed and implemented the VTE assessment
programme and tool across the Trust won the Public Sector Project of the year category in
the UK IT Industry Awards 2011 and the Healthcare IT Award in the 2011 Health Business
Awards and was shortlisted for the 2011 E-Health Insider Awards for the 'best use of IT to
promote patient safety category'.
We will continue our improvements in the areas identified in the 2010/2011 Quality Account and this
year, after listening to our patients and stakeholders we have chosen another three areas to
prioritise:
• Patient Safety – Elimination of avoidable pressure ulcers
• Clinical Effectiveness - Effective discharge from hospital
• Patient & Staff Experience – Using real time patient feedback to affect change
There is no doubt it has been a difficult year and some tough decisions have had to be made. We
know the next 12 months will bring more changes to the NHS and we need to be prepared to show
strong leadership and have the difficult discussions needed to ensure that we have a NHS that our
patients and staff deserve in the 21st Century.
I hereby state that to the best of my knowledge the information contained within the Quality Account
is accurate.

Andrew Hardy
Chief Executive Officer
UHCW NHS Trust

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1.0

Introduction to the Annual Quality Account

Current view of the Trust’s position and status for quality
Our Vision as a provider of Health Care for the local population is to deliver the best care for our
patients, achieve excellence in education and teaching and innovate through research and learning.
Pursuing this vision is our main priority and is expressed as four key strategic objectives in our
Organisational Strategy 2009-2015.

Continuous improvement in patient safety and quality is essential for the achievement of these
objectives. Patients and the public want and deserve to receive high quality healthcare. We believe
that patient experience, safety and excellent outcomes are vital to improving quality at our Hospital.
The Trust has developed a Quality Strategy that’s sets out the key principles, responsibilities and
achievements it wants to see. Achievement is one of UHCW’s core values and we are committed to
delivering safe, effective and evidence based care and achieving quality in everything we do. A
copy of the Quality Strategy is on our website and we hope that this Quality Account illustrates our
commitment to providing high quality services and being an open and transparent organisation.
Section 2 of this Account is set out under the headings of We Care, we Achieve, We Innovate. The
Account then continues to Section 3 where we have detailed our performance against national and
local targets in 2011/2012. Section 4 is the forward looking part of the Account and describes our
Quality Priorities for 2012/2013. Following this section are the statements from the Trust Board
which are the mandatory and prescribed sections of the Account which every hospital has to
include. The Account is then complete when the statements from our partners are included and, new
for this year, the Statement of Directors responsibilities. This year UHCW has also produced two
supplements in addition to the full Quality Account. These detail further information regarding our
Clinical Audit and Effectiveness programme and the indicators agreed with our Commissioners as
CQUINs. These can be found on our website at www.uhcw.nhs.uk

Overview of Last Year’s Quality Account Priorities
UHCW recognises that some of last year’s actions relating to the Quality Priorities had a mixture of
quantitative and qualitative measures which were not specific enough to inform you of all the actual
benefits the action has had. This is something we have put right in our priorities for this year, and

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where possible have stated the starting position, or baseline as it is commonly known, and the
overall target we aim to achieve. This means that in our 2012/2013 Quality Account you will be
better able to see the tangible benefits for patients.

Patient Safety - Management of Sepsis
Identified Area of improvement

Progress

Make the sepsis pathway documentation more
readily available and easier to file within the
health records, e.g. by the use of stickers or
pre-punched sheets, and increase awareness
of the ‘Do you Speak Sepsis’ campaign.

Documentation was revised to include easily
visible sepsis management stickers that staff can
record information on and put into the health
record. A recent audit has demonstrated that there
is evidence of improved compliance with the
administration of antibiotics since this was put in
place.
In addition A3 sepsis pathway posters were placed
on every nursing station alongside a dedicated
training programme. Credit card type information
was also produced so staff could wear it with their
ID badges for easy reference. The Trust also
undertook a large communications campaign twice
in 2011 with another planned for this year.

Develop the process for timely communication
of results from Pathology to clinicians.

The pathology laboratory have put into place a
system to alert clinicians on wards of specific
abnormal results. The time of the call is
documented in CRRS our electronic clinical results
system so that staff are alerted immediately.
A new style form has been developed for medical
patients which is similar to major trauma
documentation. This includes a one sheet form
that staff can record observations, actions and
information on so that it is all in one place. It is
currently being piloted to ensure its effectiveness.
We are currently looking at the feasibility of
measuring a one hour standard from decision to
admit to admission to the general Critical Care
unit.

Develop medical trauma documentation,
similar to that currently used for major trauma
& develop clearer lines of responsibility for
patients who are released from the
resuscitation area.
Introduction of the use of “score to door” times.
These may be useful to measure response
times when patients trigger parameters that
suggest severe infections. Once this
information is collected regularly “run charts”
can be used to assess the impact of further
initiatives and changes in practice and delivery
of care.

Monthly meeting of the Nutrition steering group
reconstituted and chaired by the Chief Medical
Officer.
A New consultant in Gastroenterology has been
appointed with dedicated time for Nutrition.

6

Identified Area of improvement

Progress

Introduce outpatient nutrition risk screening at
a first outpatient appointment

Patients are now weighed at first outpatient
appointment
Patient information leaflets written for moderate to
high risk patients.
A new plan has been agreed for Nutrition
screening to change to MUST screening tool with
implementation for January to April 2013.
Completed and in place, complex and difficult
cases are not discussed in a multi-disciplinary
forum,

To introduce weekly Nutrition Team Multi
Disciplinary meetings to discuss difficult cases
relating to enteral or parenteral nutrition in
hospital or the community.
To improve compliance with inpatient nutrition
screening

To introduce a dedicated central line insertion
service.

To implement and monitor nutrition and
hydration in line with requirements for DH High
Impact Actions.
To implement NPSA guidance on nasogastric
tube insertion by September 2011
To implement â&#x20AC;&#x153;Eatwellâ&#x20AC;? menu.

To consider changing from the locally
developed Nutrition Screening Tool to
Malnutrition Universal Screening Tool (MUST)
in 2012.

Programme of training ward staff , high
dependency units and Medical staff completed
and ongoing,
Nutrition study days are ongoing
A booking system implemented for a central line
insertion service.
A business case to improve access further is
being developed.
Still awaiting national guidance, as no national
targets have been confirmed, UHCW is continuing
to monitor nutrition and hydration as per UHCW
guidelines.
Completed and compliant. NG tubes and Gastric
aspirate testing strips introduced.
Behind schedule for completion. The members of
a project team have been identified and an
implementation plan is to be developed.
Nutrition Steering Group agreed the use of the
MUST tool. A plan has been agreed to implement
it for inpatients in 2012 and outpatients in 2013.

Completed. This has resulted in care pathways
being introduced to care more effectively for those
patients with dementia.
The lounge and memory lane opened for use at
the beginning of September 2011 and were
officially opened by the Lord Mayor on 1st
December 2011 to coincide with a Dementia
Conference the Trust was hosting. The Lounge
has been a success and has proved to be a quiet
and calm environment which has helped many
patients and their families. The Memory Lane has
proved to be a talking point for patient, staff and
relatives alike often eliciting a smile and

Completion of Forget Me Not Lounge and
Memory Lane

7

Identified Area of improvement

Development of an observational policy for
vulnerable patients.
Develop a Pathway for older patients with
Dementia/delirium/physical frailty.
Rolling programme of Dementia and Delirium
awareness for all front line staff.

Developing an on-going programme of
training, addressing issues of care for older
people.
Development of joint nursing and medical
protocols regarding the management of
challenging behaviour.
Multi-professional working group to be set up
to work on various issues firstly to look at
reducing use of anti-psychotic medication.

Develop intermediate level of training and
possibly link it to an NVQ.

Create a better environment

Progress
sometimes a tear.
Completed – the policy has been completed and is
being used across the Trust.
Completed- being updated to incorporate CQUIN
target around “FAIR” (Find, assess, investigate
and refer.)
Awareness training has been delivered to over
4200 staff and is now included on our corporate
induction for new starters. We have launched the
CORE (Communicate, Orientate, Reassure and
Environment) campaign and a new awareness
programme to commence around “FAIR” (Find,
assess, investigate and refer.)
Training programme continues. Specific topics
such as mental capacity assessment and
challenging behaviour being addressed.
Complete and in use across the Trust. Staff have
guidance in which they can feel confident to
manage patients who have challenging behaviour.
Group was set up and did an initial audit of the use
of anti-psychotic drugs. Results demonstrated very
low usage. A re-audit will commence shortly, we
are hopeful that the use of anti-psychotic
medication, will be reduced further.
Dr Bart Sheehan Associate Clinical Professor of
Old Age Psychiatry at Warwick University spoke at
the UHCW Dementia conference in December,
and was very well received. His recommendations
are being used to inform future practice.
The Clinical Nurse Specialist (CNS) for Dementia
Care Rose O’Malley holds a Post Graduate
certificate in Dementia Care and along with the
CNS for Older People, Elizabeth Kiernan who is
undertaking an MSc in Dementia care, are using
this knowledge to train at different levels in the
Trust for different staff groups. Over 2011/2012 it
was agreed the NVQ style of training and learning
is not fit for purpose and the CNS for Dementia is
hoping to undertake a training course to be an
accredited trainer of staff. This will enable higher
level training to be administered in house by an
accredited professional.
We worked with the King’s Fund and now have a
number of staff, including from Estates and our
PFI partners, trained in the Enhancing the Healing
Environment principles. In late 2011/12, we
adopted these principles for use across the Trust
and during 2012/13 we will use these principles,
which include key elements of patient and public
engagement, in our planned refurbishment
activities within our Better Patient Environment

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Identified Area of improvement

Progress
Programme.

For Pictures of the Dementia Lounge and Memory Lane please access the Quality pages of
our internet site. www.uhcw.nhs.uk

2.0

Overview of Organisational Quality

We Care
2.1

Incident Management

We are very proud of our incident management policy, whereby staff can report incidents, knowing
that they will be supported throughout the process of investigation and can contribute to the resulting
recommendations and actions. By encouraging staff to report when things go wrong we can learn
and share improvement strategies both within the hospital as well as externally.
We are enhancing our online incident reporting system (Datix) year on year, accelerating the
investigation process and the production of action plans so that the learning is fed back into practice
more quickly. We have also developed more sophisticated reports from the system, providing
greater scope for aggregation and analysis of incidents.
Overall incident reporting shows an upward trend towards the 10% of all admissions rate which is
quoted as the average for hospitals in England.
In our peer group of acute teaching hospitals a recent National Patient Safety Agency (NPSA) report
shows UHCW as being 6th out of 27 Trusts in terms of our reporting rate (see Figure 1), which
indicates an open safety culture that supports improvement.

Figure 1: Reporting Patient Safety Incidents. Rate per 100 Admissions

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The same report shows that the vast
majority of reports are “no harm”
incidents as indicated in figure 2. This
illustrates that UHCW is regarded as
one of the safest teaching hospitals in
England.
Figure 2: Incidents reported by Degree of
harm April 11- Sept 11

2.2

Serious Incidents Requiring Investigation (SIRIs)

We reported a total of 253 SIRIs in 2011/12. Some specific types of incident are automatically
reported as SIRIs; examples of these are Never Events, MRSA bacteraemia, C Difficile-associated
deaths or outbreaks, pressure ulcers and certain Maternity-related incidents. These account for
84% of SIRIs reported.
Many measures have been implemented as a result of SIRIs. Here are some examples:
• A drive within the Trust to ensure all staff are trained in Information Governance, particularly
on the procedures for dealing with confidential and sensitive material. Awareness has and is
continually being raised through communications and newsletters
• Falls prevention - a key focus has been on the education of staff in relation to undertaking
patient risk assessments and actions to minimise the risk of them falling. A falls resource
folder has been developed for the clinical areas and implementation is being supported by
education sessions in practice. Ward 40 a care of the elderly ward has seen a 50% reduction
in falls since July 2011.
• Staff training and improved risk assessment tools were introduced in the Emergency
Department to enhance the treatment of patients at risk of suicide.

2.3

Never Events

UHCW had 2 wrong site surgical never events during 2011/12 (for year on year comparison please
see page 30). Key actions were identified and immediately implemented to reduce the likelihood
occurring again. The Trust uses the World Health Organisation’s (WHO) surgical safety checklist,
this is a mandatory process that when followed minimises the risk of surgical errors happening, but it
cannot prevent all untoward events. In response to these 2 never events we have acted swiftly to
ensure compliance in all theatres. We have closely monitored compliance with the checklist with the
aim of achieving consistent 100% compliance during 2012/13.
We also had one retained foreign body post-operation never event. This was a most unusual
incident involving a small piece of disposable equipment that was not part of any theatre counting
processes. This event has led to us adopting more rigorous checking procedures with all
instruments, covers and packaging used in the operating theatre environment. We have shared the
learning from this incident with both local and national healthcare organisations.

10

2.4

Trust Board Patient Safety Walkrounds

The Trust formally introduced Trust Board Patient Safety Walkrounds in May 2010, using the
National Patient Safety Agencyâ&#x20AC;&#x2122;s (NPSA) guidance from their Patient Safety First Campaign.
Walkrounds demonstrate top level commitment to patient safety, establish lines of communication
about patient safety between staff, executives and managers, provide opportunities for senior
executives to learn about patient safety and promote a culture of openness. Chief Officers and nonExecutives are scheduled to visit
staff in their own wards and
departments, agreeing to support
and assist the staff with issues that
they cannot move forward alone.
Staff are aware of the dates for their
visits and therefore have an
opportunity to raise specific issues or
problems as well as being able to
showcase examples of good practice
to the Executives.
Walkrounds occur each month
across the organisation on both sites and any actions agreed are logged and monitored by the
Quality & Patient Safety Team. A schedule has been drawn up for 2012/13 and the Executive team
is keen to promote and support this important aspect of patient safety and quality.

2.5

NHS Litigation Authority (NHSLA) Status

The Trust is a member of the NHSLA Risk Management schemes for Acute Trusts and Maternity
Services. There are separate manuals of NHSLA standards for the schemes, each comprising 50
criteria. A minimum score of 40/50 is required to pass each of 3 levels of assessment. Whilst the
aim of the Trust is to achieve the highest level of assessment (level 3) it is only permissible to be
assessed at one level within a financial year and progression has to be through each level in turn
and normally takes at least two years to achieve each level.
The Trust was successfully assessed against the level 1 acute standards in 2010, enabling us to
progress towards the next level of assessment. A two-day level 2 assessment is scheduled for
September 2012. Designated corporate leads have responsibility for ensuring policies and
procedures are compliant with the NHSLA requirements and (in conjunction with the clinical
specialties) ensuring that there is sufficient evidence of â&#x20AC;&#x153;policy in practiceâ&#x20AC;? to present to the
assessors. The plan is led and monitored by the Quality and Patient Safety Team, who provide
regular progress reports to the Executive team.
The Maternity Services were successfully assessed against the level 2 Maternity standards in 2009.
The Maternity standards are led and monitored primarily by the service itself due to the specialised
clinical nature of most of the criteria. The QPS Team provides support and liaison with the Maternity
Services to ensure that the evidence matches the requirements of the standards.

2.6

Claims

The Trust as at 5th April 2012 had reported 70 clinical negligence claims to the National Health
Service Litigation Agency (NHSLA). In 2011/12 the NHSLA, on behalf of the Trust, settled 63

11

claims. Further details on the Trust's claims history can be obtained via the NHSLA's
website www.nhsla.com. We can confirm that the Trust's clinical negligence claims history is within
the national average for Acute Trusts providing a maternity service.
The Trust is committed to minimising the opportunity for human error in medicine and with this aim
has committed substantial resources in implementing its clinical governance framework. Clinical
adverse events are actively reported and as appropriate investigated; with action plans implemented
seeking to avoid similar incidents again.

2.7

Complaints and PALS

During 2011/12 we received 497 formal complaints. We had 25 complaints taken up by the Health
and Social Care Ombudsman but in most cases these were closed without further action or we were
afforded the opportunity to again try and resolve the complaint locally. 3 complaints were
investigated by the Ombudsman during this financial year and were either upheld or partially upheld.
We report to the Patient Engagement & Experience Group, Patient Safety Committee, Clinical
Governance Review Group and Trust Board information and details on Complaints. Also during
2011/12 we have involved non-executive directors and a lay director in reviewing a selection of our
complaints responses.

Total Number of Complaints

2009/10 2010/11 2011/12

Total Number of Complaints - University Hospital,

443

443

450

34

60

44

7

9

3

484

512

497

20

24

25

Coventry
Total Number of Complaints -Hospital of St. Cross ,
Rugby
Total Number of Complaints - Other
TOTALS

Total number of complaints referred for
independent review
Top Five Complaint Categories 2011/2012*
All aspects of clinical treatment

254

Attitude of staff

78

Communication/information to patients (written and oral)

60

Failure to follow agreed procedure

25

Appointments, delay/cancellation (in-patient)

22

Ratio of Complaints to Activity
888,428 917,161 911,206
0.05%

0.05%

0.05%

Table 1. 2011/2012 Complaints Data
(* The complaint categories are prescribed to the Trust by the NHS information Centre for Health and Social care and
form part of a mandatory return called the KO14a)

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In early 2012 a full report on our response to the Francis Report from the Mid-Staffs enquiry in
respect of complaints and complaints handling was presented to a Trust Board seminar. The
complaints handling processes we use were audited on several occasions during the year with no
significant issues for action being identified. Our internal auditors gave the following levels of
assurance.

Key control objective

Level of Assurance
Full

There are mechanisms in place to
accurately identify, record, act upon and
monitor complaints in respect of all forms of
health services accessed by patients of
UHCW NHS Trust.

Significant

Moderate

Limited

None

Robust processes are in place to make
service improvements where
Deemed necessary and assess whether
actions taken have had the desired effect.

Table 2. Internal audit summary of Assurance

2.8

Patient Advice and Liaison Service (PALS)

During 2011/12 we received 1247 PALS enquiries. This is compared to 2130 in 2010/2011. A
number of factors will have contributed to this fall in numbers. Firstly, following a review of the
service, including a change in personnel and a review of
the data capture methodologies in use, it became
apparent that many simple requests for information that
could be answered immediately and that should have
been
dealt
with
by
switchboard,
reception,
communications, front-line service teams, ward staff or
health information centre staff (e.g. service opening times,
directions to departments/wards, visiting times, information
about specific conditions/procedures, what ward a
particular patient might be on etc.) had been previously
recorded as formal PALS enquiries.
This clearly was not appropriate and was ceased.
Only genuine PALS issues, i.e. those requiring PALS staff
action are now recorded within the PALS figures. It was
also discovered that there were issues with data quality
due to a significant backlog in PALS data entry, as a result
of unplanned staff shortages due to long-term
sickness and retirement, and inappropriate use of the recording system in place. The data backlog
has been addressed, applying the correct criteria for PALS contacts, as highlighted above. We
believe that this accounts in most part for the drop in PALS contact figures. The top 5 themes are
detailed in Table 3.

During 2011/12 we have presented a number of patient stories to our Trust Board using a variety of
formats including films, written submissions and web postings. These have covered a variety of
issues including access and parking, communications, nursing care, care for patients with dementia,
equipment availability and patient feeding. During 2012/13 we are committed to taking such stories
to each Trust Board.
In September 2011 we presented a report on our Patient Engagement & Experience Progress
following a full year of having a dedicated Engagement Directorate. During 2012/13, in line with our
Patient Revolution Strategy, we will be moving towards a Patient Services (Customer Services
equivalent) model of service provision for PALS and Complaints.

2.9

Patient Satisfaction Surveys

During 2011/12 we participated in 2 national patient surveys covering In-Patients and Out-Patients.
Both surveys are conducted by the Care Quality Commission (CQC). The CQC ask people to state
what they thought about different aspects of the care and treatment they received. Each NHS Trust
receives scores out of 10, based on the responses given
by their patients. A higher score is better. Each Trust
also receives a rating. The rating ‘better’ means that the
Trust is better than most other Trusts who took part in
the survey for that particular question, a rating of ‘about
the same’ means that the Trust is about the same as
most other Trusts and a rating of ‘worse’ means that the
Trust did not perform as well as most other Trusts for
that question.
For our in-patients the CQC sent 850 questionnaires out
to recent inpatients, they received 446 back. The below
tables represent the main categories of questions that
were asked, underneath each of these are another series of scores and ratings. For this detailed
information please go to the UHCW pages on the CQC website www.cqc.org.uk.

14

For our in-patients:
Score out of 10
7.7

Patient were asked Questions
about:
A&E and emergency

6.3

Waiting lists and planned admissions

7.1

Waiting to get to a bed on a ward

8.2

The hospital and the ward

8.4

Doctors

8.1

Nurses

7.1

Care and Treatment

8.2

Operations and Procedures

6.6

Leaving hospital

5.5

Overall views and experience

Rating compared to
other Trusts

For our out-patients; responses were received from 473 patients:
Score out of 10
7.4

Patient were asked Questions
about:
Before the Appointment

4.4

Waiting in the hospital

8.7

Hospital environment & Facilities

7.9

Tests and treatment

8.6

Seeing a Doctor

8.6

Seeing another health professional

15

Rating compared to
other Trusts

Score out of 10
8.2

Patient were asked Questions
about:
Overall about the appointment

6.9

Leaving the Outpatients department

8.7

Overall Impression

Rating compared to
other Trusts

From both these surveys, even though the Trust is ‘about the same’ as compared to other Trusts in
England actions plans have been drawn up to address areas where our patient experience is not
where we would expect it to be. These actions will be monitored through our Patient Engagement
and Experience Group. As well as the national surveys, UHCW continues to use its own survey tool
called ‘Impressions’. We survey more people over the year, of the impression they have of UHCW
and the results are below:
Category
No of
Overall
Overall
respondents
10/11

As illustrated above, for the past 2 years our lowest scoring category on Impressions has been car
parking. Our key focus for 12/13 is to address the ongoing traffic congestion problems at the
Coventry site. UHCW is pleased to state that it has been given permission to build an extra 433 car
parking spaces on wasteland on University Hospital site.
The new car park will allow the Trust to create more spaces for staff, patients and visitors in the new
development and existing car parks. Lincoln Dawkin, Director of Estates said:
“We are delighted that this application has been given the support of the planning
committee and will work with the planning team to address the remaining issues. The Trust
will commence discussions shortly to finalise details and ensure outstanding concerns are
addressed and would hope to start developing the extra car parking spaces at University
Hospital during July.”
This car parking application is one of a number of initiatives UHCW has introduced in their
commitment to improve car parking and access to University Hospital site. In May 2011, the Trust
significantly reduced car parking charges and for certain patient’s car parking is free of charge.
Paying is easier too with extra pay stations recently installed. The Trust has also agreed with its
service provider to install Chip and Pin machines at all pay stations, it is hoped this work will be
completed in early July.
The Trust has also created an additional 50 car parking spaces for the public this year and trialled a
one-way system which gave priority to ambulances, buses and taxis. The results from this trial are
still being reviewed but there was lots of positive feedback about how it reduced congestion on
University Hospital’s site. The Trust will look into traffic flows and the layout of the site to introduce
this on a permanent basis in the coming months. Furthermore, when patients enter University
Hospital a new way finding service run by volunteers has been introduced.
The Trust plans to continually improve car parking and access to University Hospital site, and is
keen to move forward and assist Gallagher Estates with plans to build a second entrance and
additional car parking as the next significant improvement.
To find out more information about these initiatives please contact Lincoln Dawkin, Director
of Estates and Facilities on Lincoln.Dawkin@uhcw.nhs.uk or Telephone 024 76968496.

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2.11

Patient Reported Outcome Measures (PROMs)

Patient Reported Outcome Measures (PROMs) are a means of collecting information on the
effectiveness of care delivered to NHS patients in England as perceived by the patients themselves.
NHS hospitals have been collecting this information from April 2009. Information is collected on
patients who undergo the following procedures:
• Unilateral hip replacements, both primary and revision surgery;
• Unilateral knee replacements, both primary and revision;
• Groin hernia surgery;
• Varicose vein surgery.
Within UHCW, in common with other hospitals, information has been collected on the above
procedures using questionnaires pre-operatively. All patients are asked to complete two scores of
their general health and wellbeing. These are:
• An Index Score which reflects general health status and captures condition specific issues in
a broad way;
• A Visual Analogue Score (VAS) which is derived from a single score on a scale of 100 (best)
to 1 (worst). This score asks patients to score their general health on the day they complete
the questionnaire and provides an indication of the patient’s health that may not be
necessarily associated with the condition for which they were treated. This score can also
be affected by non health related factors;
• Refer to pg 31 for latest results

2.12

Staff Survey 2011

The NHS staff survey is undertaken nationally by all Trusts within the NHS on an annual basis and
takes place between October and
December. A random sample of 850 staff
are selected from each Trust and asked to
complete a confidential questionnaire
which is personally addressed to them. At
our Trust we also attach a personal letter
from the Chief Executive explaining the
importance
of
this
survey
and
encouraging our staff to complete this.
In 2011 our response rate was 51%
(430:850 replies) compared to 42% in
2010 and the national mean response
rate for acute Trusts was 54% in 2011. The overall purpose of this survey is to gauge the degree of
staff engagement and to find out the effects of 4 staff pledges within the NHS Constitution and is
therefore employee centric in its design:Pledge 1

-

to provide all staff with clear roles and responsibilities and rewarding jobs for
teams and individuals that make a difference to patients, their families and
carers and communities.

Pledge 2

-

to provide all staff with personal development, access to appropriate training
for their jobs and line management support to succeed.

Pledge 3

-

to provide support and opportunities for staff to maintain their health, well being

18

and safety.
Pledge 4

-

to engage staff in decision that affect them and the services they provide,
individually, through representative organisations, and through local
partnerships arrangements. All staff will be empowered to put forward ways to
deliver better and safer services and their families.

Key Findings
Our top 4 rankings (compared to all other acute Trusts) are
•

% of staff suffering work related injury is 12% compared to 16%. In 2010 the Trust’s % was
19% so a noticeable positive improvement

•

% of staff experiencing harassment, bullying or abuse from staff in the last 12 months is 13%
compared to 16%. In 2010 the Trust’s % was 19% so a noticeable difference

•

Staff motivation at work was 3.88 (highest rating is 5) compared to 3.82. In 2010 the Trust’s
score was 3.86

•

% of staff having equality and diversity training in the last 12 months is 61% compared to
48%. In 2010 the Trust’s % was 69%. This change is likely to be due to less staff requiring
mandatory training during 2011 as the compliance has substantially improved

Staff Pledges.
Pledge 1- to provide all staff with clear roles and responsibilities and rewarding jobs for teams and
individuals that make a difference to patients, their families and carers and communities.
•
•
•

75% of our staff are feeling satisfied with the quality of work and patient care they are
able to deliver
89% of our staff agree their roles make a difference to patients
78% of our staff feel valued by their colleagues

Pledge 2-Training, Learning and Development
In the last 12 months:•
•
•

79% of staff received job relevant training, learning and development
86% received health and safety training
75% staff had an appraisal with a PDP

Pledge 3- to provide support and opportunities for staff to maintain their health, well being and
safety
•

96% of staff reported errors, near misses or incidents in the last month

19

Pledge 4-to engage staff in decisions that affect them and the services they provide, individually,
through representative organisations, and through local partnerships arrangements. All staff will be
empowered to put forward ways to deliver better and safer services and their families
Our staff continue to recommend the Trust as place to work or receive treatment- 3.49 out of
a maximum score of 5
Equality and Diversity
89% of staff believe that the Trust provides equal opportunities for career progression or promotion,
compared to 85% in 2010. The national average is 90%

2.13

Same Sex Accommodation

The NHS Operating Framework for 2011/12 requires all providers of NHS funded care to confirm
whether they are compliant with the national definition “to eliminate mixed sex accommodation
except where it is in the overall best interests of the patients, or reflects their patient choice”. UHCW
has in place an ethos that supports dignity in care and ensures delivery of our Same-Sex
Accommodation policy. This approach consists of four
main areas:
1. Patient Experience is monitored through surveys and
direct observations (I.e. Executive, Senior Nurse and lay
representative’s Walkrounds) to gather important
information about dignity in care including single sex
compliance. This is reviewed by the clinical teams with a
clear governance system in place to ensure that any
issues are escalated and actioned.
2. Estates. As a new building, the design incorporated a
number of features to improve dignity, including 40% side rooms with en-suites, 4 bed bays with
localised washing and toileting facilities, privacy doors on bay entrances. This enables segregation
of sexes in all ward areas including toileting and washing, which is re-enforced with clear signage
and staff awareness.
3. Systems and Processes. There is a robust breach monitoring system that is shared with the PCT
and SHA. This information is reviewed and monitored through Chief Officers and the Board.
4. Staff Culture. Dignity in care is key component of all health care professions focus at UHCW. In
clinical training dignity issues of patients is included.
During 2011/12, UHCW experienced 1 single sex breach. This occurred on the intensive care unit
as the patient breached the time limit after discharge. A full review was undertaken and escalation
policy introduced to prevent a re-occurrence.

20

2.14

Closure of Birch Ward at Hospital of St Cross Rugby

UHCW reduced its bed base by 22 beds in November 2011 by closing Birch Ward. Now 6 months
post closure, we can evaluate the real impact of the closure.
The graph below demonstrates that since Birch ward closed, University Hospital Coventry has been
at an average of 93.91% occupancy across the Trust. This is a slight increase of just 1.2% in
occupancy from the same period last year.

Figure 3. Occupied Bed levels at UHCW Dec 2010 – May 2012

The Hospital of St Cross has seen a decrease in occupancy of just 0.9% from 86.2% to 85.3% for
the periods under review. To minimise the impact of reducing the bed base on performance and
quality and improve the patient experience, focussed attention was given to improving discharge.
The result of this is that patients who were historically transferred to St Cross for the final few days
of their episode of care are now managed more appropriately at University Hospital (UH) and
discharged from there directly. This can be evidenced by the increase in discharge rates at UH and
a reduction in transfers to St Cross. Conversely the discharge rates at St Cross have decreased
slightly since November as you would expect given the reduction in bed base. Better discharge
planning at UH is resulting in a cohort of patients with more complex discharge needs at Rugby.
Orthopaedic and Surgical activity continues to be delivered at St Cross with theatres indicating an
improved utilisation particularly for orthopaedic activity January through to March 2012. The overall
satisfaction with both hospitals has actually slightly improved over the last few months from its
already high standard. The information below is taken from ‘Impressions’.
Overall satisfaction levels with Hospitals April 2011 – November 2011:
University Hospital: 93%
Hospital of St Cross: 92%
Overall satisfaction levels with Hospitals December 2011 – April 2012:
University Hospital: 96%
Hospital of St Cross: 94%

21

This coupled with relatively static complaints data, would suggest that patients have not perceived
there to be a detrimental impact on the provision of a quality, safe and effective service following the
closure.

We Achieve
2.15

VTE Risk Assessment

UHCW was one of the first Trusts in the country to meet the Government’s target to risk assess 90%
of patients against developing Venous Thromboembolism (VTE). VTE includes deep vein
thrombosis (DVT) which is when a blood clot forms within a major leg vein and pulmonary embolism
when a DVT breaks off and travels to the lungs.
VTE is one of the leading causes of death in hospitals resulting in up to 25,000 preventable deaths
each year. Because of this the Government set a target for 90% of adult inpatients to be risk
assessed for VTE from January 1, 2011. UHCW implemented an innovative electronic solution
which has not only helped it become one of the first to reach the 90% target nationally and three
months ahead of the January 2011 deadline.
The e-solution is colour coded to allow staff to see at a glance whether the risk assessment has
been done or not. They are then presented with a simple checklist which when entered displays
appropriate clinical advice/ action to take dependant on selected risk factors.
A multi-disciplinary team lead by Consultant Haematologist Dr Oliver Chapman was established to
oversee the implementation of the new VTE tool with members from IT, nursing, management,
training and communications.
Due to its success the VTE team won the Public Sector Project of the year category in the UK IT
Industry Awards 2011 and won the Healthcare IT Award 2011 in the Health Business Awards. The
team was also nominated for the prestigious E-health Insider Award under the category of “Best use
of IT to promote patient safety”.

Dr Chapman said: “As a team we are proud
of the work we have done to improve
patient safety. By implementing an e-tool
that’s quick and easy to use, we helped
ensure staff would be able to complete the
assessments, patients would benefit from it
and the Trust would reach its goal.”

2.16

Understanding Mortality

UHCW subscribes to Dr Foster’s Real Time Monitoring tool and has been monitoring Hospital
Standardised Mortality rates (HSMR) for a number of years with clinicians being able to access their
own specialties information. HSMR is calculated using the number of deaths at a hospital Trust
compared with the number of patients who would be expected to die, taking into account age,
complexity of illness, deprivation and gender. The baseline for England is set at 100 and a lower
figure indicates fewer patients died than expected.

The Trust monitors its mortality rate or HSMR on a routine basis and for 2011/2012 it was 94, which
in essence means that 6% less people are dying than expected. Every year Dr Foster rebases its
figures. Rebasing is needed because the HSMR figure is a comparison with what is expected, and
the expected value is calculated from actual mortality figures from all hospitals and normalised to a
value of 100. As standards in hospitals improve, actual mortality rates will decrease, but Dr Foster
keeps the expected value at 100, and mortality ratios are adjusted in relation. It is expected that
when Dr Foster rebases in 2012 our HSMR will rise to an estimated 103.
The Francis Inquiry in to Mid Staffordshire NHS Trust prompted UHCW to set up a dedicated
Mortality Review Group with hospital and commissioner membership. A post was also developed to
support mortality review across the Trust. In 2011/2012 UHCW instigated a Trust wide process
whereby all deaths over the age of 18 were systematically reviewed using an electronic, evidence
based form which requires the Consultant to classify the deaths according to categories of care
defined by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). These
are:
A Good Practice: A standard you would accept for yourself, your trainees and your
institution
B Room for Improvement Clinical: Aspects of Clinical Care that could have been better
C Room for Improvement Organisational: Aspects of Organisational Care that could have
been better.
D Room for Improvement Clinical and Organisational: Aspects of both Clinical and
Organisational Care that could have been better.
E Less than satisfactory: Several aspects of clinical and / or organisational care that were
below that you would accept for yourself, your trainees and your institution
Feedback from the initial review is fed back to specialties on their Quality and Patient Safety
Dashboards and discussion and actions are recorded and monitored through Mortality Review
Group that is chaired by the Chief Medical Officer. This way the organisational learning for patient

23

deaths can be spread leading to improvements in patient care. This was a CQUIN in 2011/2012 and
the Trust achieved the required 75% mortality review rate. In 2011 the Department of Health
released a new mortality indicator for hospitals called the Summary Hospital Mortality Index (SHMI).
The SHMI is different from the HSMR in the following ways;
• The SHMI includes all deaths, while the HSMR includes a basket of 56 diagnoses (around
85% of deaths).
•

The SHMI includes post-discharge deaths, while the HSMR focuses on in-hospital deaths.

•

The HSMR is adjusted for more factors than the SHMI, most significantly palliative care but
also including social deprivation, past history of admissions, month of admission and source
of admission.

UHCWs current SHMI is illustrated in Figure 5 below compared to our other hospitals in the West
Midlands.

2.17

Healthcare Acquired Infections

MRSA BACTERAEMIAS
The Trust continued to perform well in 2011/2012. We had a target of 4 for 2011/2012, and as
detailed in the table below UHCW only had one MRSA bacteraemia. This is fantastic achievement
and the Trust has been MRSA bacteraemia free since July 2011.
Quarter
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter

2008/09
3
10
2
2

2009/10
3
2
2
1

2010/11
1
1
1
1

2011/12
1
0
0
0

Table 5. MRSA Bacteraemias Reported by Quarter / Year

24

CLOSTRIDIUM DIFFICLE (C. diff)
The management of the C diff target has been troubled throughout the country for this financial year.
Trusts were actively encouraged to change their testing algorithms to a more sensitive methodology
ahead of the recommendation of a national study. A new testing regimen was therefore introduced
in October 2011. This dramatically altered the numbers of cases detected. On clinical review most of
these patients were thought to not be infected with C. diff. This seemed to be replicated across the
country. In January 2012 the results of the national study were published which showed that UHCW
had in place the best testing methodology as far back as 2009.
The pressure to change to a new
methodology was totally unfounded as the
report showed that the new test many
hospitals had been driven to adopt was
oversensitive diagnosing patients with C. diff
infection when in fact they were not infected
The figures for October/ November and
December which amount to 36 cases using
the new test (42 % of the annual target) are a
gross overestimation of the true number of C.
diff cases (we estimate the true number to be
8). However despite protestations to both the
Health Protection Agency (HPA) and
Department of Health (DH) we have so far not been given the option to correct the data on the
national website. This is a great shame as the correct figures would show that the Trust has not only
come within target but is substantially below this having a rate of infection that matches the best
hospitals. This still represents a 14% improvement on last year’s 104 positive C diff cases.
Quarter
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Total

2008/09
50
32
36
29
147

2009/10
27
28
26
35
116

2010/11
39
18
23
24
104

2011/12
22
22
36
10
90

Table 6. C Difficile reported by Quarter/ Year

CLEANING
The environment is becoming increasingly recognised as a source of organisms leading to cross
infection. Good cleaning standards as a consequence are essential to reducing rates of infection, in
particular C diff. A number of changes have occurred during the year to aid the improvement.
• Adopting the Infection Control Nursing Association Audit (ICNA) tool to assess the
environment as a reservoir for infection has increased awareness amongst staff that
providing a clean and safe environment for patients is the responsibility of all staff. This
tool is used nationally by infection prevention and control teams and has been used since
2004
• A performance management system which calls to account areas who fail two
consecutive audits. A third fail will result in an interview with the Chief Nursing Officer to
discuss action plans which the Matron/ Ward manager.

25

â&#x20AC;˘
â&#x20AC;˘

A failed question report based on the prior two weeks audits are brought to the
operational cleaning group for discussion and addressing.
A bi weekly audit report shows those areas which have had an ICNA audit and their
resulting scores again for discussion; this also gives a more strategic view of the general
environment and any variances in standards.

For more information on Infection control and Prevention at UHCW please contact Dr Mike
Weinbren, Consultant Microbiologist. Michael.Weinbren@uhcw.nhs.uk

2.18

Patient Environment Action Team (PEAT)
PEAT is an annual assessment of inpatient healthcare sites in England with 10 or more inpatient
beds. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of
patient care including environment, food, privacy and dignity. The assessment results help to
highlight areas for improvement and share best practice across healthcare organisations in England.
NHS Trusts are each given scores from 1
(unacceptable) to 5 (excellent) for standards of
environment, food and dignity and privacy within
buildings. The scores demonstrate how well
individual healthcare providers believe they are
performing in the key areas (such as food,
cleanliness,
infection
control,
patient
environment, privacy and dignity). Our 2011
results are below.
Site Name
University Hospital
Hospital of St Cross

Environment
Score
Good
Good

Food Score
Excellent
Excellent

Privacy & Dignity
Score
Excellent
Excellent

To find out how we performed in previous years please look at the 2010/2011 Quality Account also
located on our website.

2.19

CQUIN (Commissioning for Quality and Innovation)

The CQUIN schemes are an agreement between the Trust and our local Primary Care Trusts, NHS
Warwickshire and NHS Coventry, now known as The Arden Cluster. The aim of CQUIN Schemes is
to agree priorities for improvement and agree stretching goals to achieve, that have a financial
incentive attached to them. Please access the CQUIN supplement located on our website to read
more about our performance in 2011/2012.

We Innovate
2.20

Clinical Evidence Based Information Service (CEBIS)

CEBIS aims to promote, educate and facilitate the use of research evidence in practice. As an
integral part of the clinical team, the CEBIS Specialist provides a ranked summary of available
evidence in response to clinical questions. The CEBIS Specialist then jointly works with a junior

26

doctor/s to produce a critique of the evidence for open discussion and decision making within the
Specialty’s ‘Evidence in Practice Group’ (EPG).
The objectives of CEBIS are threefold, to:
1. improve information literacy, resource awareness and critical appraisal skills
2. enable evidence based decision making for quality patient care in a timely and effective manner
3. provide an archive of evidence summaries and presentations for reference and education
The short term impact has been the implementation of the CEBIS model within the Trust with a
number of Specialties. Evidence summaries, and particularly EPGs have resulted in changes to
practice and cost savings within the Trust. Feedback has been extremely positive. The need to
improve information literacy has been highlighted. As a result, we have initiated a small pilot CEBIS
Mentorship programme for Foundation Year 2 doctors to be evaluated at the end of the year. In the
longer term, a CEBIS System is being developed which will be available on the Trust Intranet. This
will be a searchable tool for all the work produced by CEBIS. It will also link to our hospital patient
management system, enabling clinical staff to refer questions to CEBIS or view relevant evidence
directly from the patient record.
2.21 Establishment of UHCW as a Major Trauma Centre
From March 26 2012 UHCW officially became a major trauma centre. This means there will now be
24 hour on site Consultant cover at University Hospital in Coventry whereas previously consultants
were on call. This move is part of a new region-wide system consisting of three trauma care
networks, each with a major trauma centre at the heart of the network and supported by the air
ambulance/ambulance services, trauma units, local emergency hospitals, specialist rehabilitation
and many other associated healthcare professionals. It is estimated that this new system could save
between 45 and 60 lives a year in the West Midlands.
The three adult major trauma centre’s are: Queen Elizabeth Hospital in Birmingham, University
Hospital in Coventry and University Hospital North Staffordshire and the children’s major trauma
centre is the Birmingham Children’s
Hospital. Independent data from the
Trauma Audit and Research Network
(TARN) shows that University Hospital
Coventry and Warwickshire NHS Trust
is currently one of the top performing
hospitals in England, for every 100
severely injured patients, an extra three
will survive in Coventry because of the
expertise and facilities. The hospital also
has the CT scanner next to the
resuscitation
department
in
the
Emergency Department so we can scan patients quicker.

27

Figure 6 – Rate of Survival at UHCW between January 1st 2008 and December 31st 2011. Source TARN.

This is a national requirement in the NHS Operating Framework in England 2011/12 that all regions
should be moving trauma service provision into regional trauma systems to make significant
improvements in the clinical outcomes for major trauma patients.
2.22 NHS Safety Thermometer
UHCW was actively involved in the development and evaluation of the NHS Safety Thermometer by
the NHS Information Centre (NHS IC). It is a tool for measuring, monitoring and analysing patient
harms and harm free care and was developed throughout the Patient Safety Express pilot from July
2010 to September 2011.
The NHS Patient Safety thermometer provides a quick and simple method for surveying patient
harms and analysing results. It can be used to measure and monitor local improvement and harm
free care over time. The harms that are monitored as part of the tool are
•
•
•
•

The harms are measured as a point prevalence of inpatients at ward level on one specified day
each month and require staff to complete an electronic proforma with information on each patient in
relation to the harms being monitored. It measures the prevalence of the specific harms as well as
proportion patients who are ‘harm free’. It enables organisations to repeatedly measure patients to
get a picture of the improvements they are making and how rapidly this is happening. The use of
the NHS Safety Thermometer will replace the current methodology for undertaking the biannual
point prevalence pressure ulcer audits, results of which are on pg 30.

28

3.0

Account of 2011/2012 Performance

Please find below a series of Quality and Patient Safety Indicators which the Trust measures on an
ongoing basis. The below have been chosen by the Trust Board to give you an opportunity to fully
understand the quality of our services. Targets are for 2011/2012.
National Priorities
2011/2012

2009/10

2010/11

CQC Essential Standards (Includes the

Licensed
without
Conditions

Licensed
without
Conditions

Licensed
without
conditions

116

104

90

11

4

1

99.9%

100%

100%

94%

95%

94%

94%

93%

92%

97%

97%

97%

97%

97%

94%

Hygiene Code- now Outcome 4)

2011/12

(Target - Licensed without conditions)

Incidents of Clostridium Difficile
(Target 86)

Incidents of MRSA Bacteraemias
(Target 4)

All cancers: 31 day wait from
diagnosis to first treatment
(Target 96%)

All cancers: two week wait from
urgent GP referral to first outpatient
appointment
(Target 93%)

Maximum waiting time of four hours in
A&E from arrival to admission,
transfer or discharge
(Target 95%)

29

Performance
against Target

National Priorities
2011/2012

Cancelled operations not admitted
within 28 day

2009/10

2010/11

2011/12

3%

4.6%

4.5%

89%

83%

86%

100%

100%

100%

62%

80%

83%

Performance
against Target

(Target 5%)

The percentage of eligible patients
with acute myocardial infarction who
received primary percutaneous
coronary intervention (PPCI) within
150 minutes of calling for professional
help
(National target 75%)

Maximum 2 week wait for Rapid
Access Chest Pain Clinic
(Target 98%)

% Patients spending more than 90%
of their stay in hospital on a stroke
unit (National Target 80%)

The below indicators are local indicators which we think are important markers of safe and effective
care. The source of data for the below indicators is UHCW unless otherwise stated.
Local Priorities 2011/2012
2009/10
2010/11
2011/12
Performance
against target/ or
last yearâ&#x20AC;&#x2122;s
performance
Pressure Ulcer Point Prevalence
Audit
Prevalence audit records the number of patients
with a hospital acquired pressure ulcer on the day of
the audit over the total number of inpatients on the
day of the audit. This is expressed as a percentage.
The lower the rate the better the Trust performs.
Includes avoidable and unavoidable pressure
ulcers. (Target: Less or equal to previous year)

Incidence of NPSA Never Events ( list

January

January

January

10

11

12

3.7%

2.9%

3.3%

1

1

3

can be found in the Glossary)
(Target 0)

30

Local Priorities 2011/2012

2009/10

Hospital Standardised Mortality Ratio
- HSMR

2010/11

98

98

100%

100%

94

95%
5% = non
participation
in 1 audit

(No national target)

Delayed Transfers of care (Target 4%)

Performance
against target/ or
last year’s
performance

Predicted
Rebased
position 103

(Source: Dr Foster Intelligence - 100 or less
indicates a good outcome)

Participation in the National Clinical
Audit and Patient Outcomes
Programme (NCAPOP)

2011/12

3.4%

5.8%

5.5%

76%

76%

76%

Definition: Delayed Transfer of care occurs when a
patient is ready for transfer from acute care, but is
still occupying an acute bed.

The National Quality Board has recommended that from 2012/2013 Quality Accounts will have a
mandatory requirement to report against a core set of 10 indicators. Although the reporting of these
is not mandatory for this year’s Quality Account UHCW has chosen to report against the majority of
them as a ‘dry run’ for next year’s Account.
NHS Outcomes
Framework
Domain
Domain 1 –
Preventing people
from dying
prematurely

questionnaires
particularly as
patients
undergoing this
procedure do not
have preoperative
assessment. As
the questionnaires
are distributed on
the day of
admission there is
a low take up rate

53.6%

(Source: WMQI Acute Dashboard
Spring 2012, Release 3.00)

Domain 4 –
ensuring that people
have a positive
experience of care

80.3%

UHCW
comments

32

There are 10
questions that
make up the
‘Responsiveness
to need’ and there
were questions
where UHCW
scored just above
5/10. Although
these were ‘about
the same’ as other
Trusts in England,
these areas will be
addressed in an
overall action plan
to tackle low
scoring areas of
the survey.
UHCW is pleased
with this
performance, and
actions to improve
on this further
have been
incorporated into
an overall action
plan submitted to
the CQC.
UHCW will
continue to be one

Domain 5 â&#x20AC;&#x201C; Treating
and caring for
people in a safe
environment and
protecting them from
avoidable harm

Rate of patient safety
incidents per 100
admissions, and;

Apr11- Sep11

% resulting in severe
harm or death

Apr 11-Sep11

(Source: WMQI Acute Dashboard
Spring 2012, Release 3.00)

0.27

National
Mean
released

data via UNIFY2)

7.92

6.31

0.42

UHCW
comments
of the highest
performers
against this
national target.
This continues to
be a national
CQUIN
This demonstrates
that UHCW has a
better rate of
reporting patient
safety incidents,
as well as a lower
% of patients
suffering incidents
which results in
severe harm or
death. This means
we are a safer
organisation.

If you are interested in receiving further information on UHCWs performance in any of the above
targets please contact Simon Reed, Head of Performance Management. Simon.Reed@uhcw.nhs.uk

33

4.0

Quality Improvement Priorities for 2012/2013

How we prioritised our Quality Improvement Priorities
In order to identify the three highest priorities for quality improvement in 2012/2013, the Trust’s Chief
Officer’s Group, chaired by the Chief Executive Officer, considered performance on patient safety,
patient experience and effectiveness of care based upon information gathered from our internal
complaints system, patient surveys both local and national, performance information, such as the
CQUIN outcomes and the views of staff, UHCW Patients Council and the Local LINKs. Performance
information listed in Section 3 of this Account also demonstrates that there is clear improvement to
be made in the three priority areas.
The Trust has agreed three priorities under which there are a number of current and planned
initiatives. This section of the report will cover the Trusts performance in these three areas and detail
the planned actions and initiatives to improve Quality for our patients, carers and families. The Trust
Board have agreed that the three selected priorities are:

Quality Priority 1- SAFETY
Elimination of Avoidable Pressure Ulcers
The elimination of avoidable grade 2, 3 and 4 pressure ulcers is one of the NHS Midlands and East
SHA ambitions to achieve by December 2012. Pressure ulcer prevention is also part of the
Department of Health QIPP agenda and the Operating framework for 2012/13 includes a new
national CQUIN goal that incentivises the use of the NHS Safety thermometer which is an
improvement tool that allows NHS organisations to measure harm in four areas of practice which
includes pressure ulcers.

Quality Priority 2 - CLINICAL EFFECTIVENESS
Increasing Effective Discharge
The current processes related to patient flow and discharge are often complex and beauracratic,
involving many professional groups. A previous lack of a dedicated Clinical Lead for patient flow and
discharge has compounded the challenges. Whilst clinical teams are working hard, we recognise
that there are internal processes which do not work as effectively as they should and the clinical
culture within UHCW do not provide the focus required to ensure efficient and timely patient flow. In
addition, many challenges also exist between UHCW and its external partners and their processes,
which need to be understood and agreements sought.

Quality Priority 3 – PATIENT &STAFF EXPERIENCE
Using real time feedback to affect change
In the Health White Paper the coalition government announced their intention to strengthen efforts to
tackle both the problem of relatively poor clinical outcomes, and that of insufficient focus on patient
experience and patient engagement. Particular emphasis was placed upon using information and
choice to empower patients, and in turn Trusts are expected to publish more information about the
quality of our care so that patients can hold us to account and see where we need to improve.

34

Quality Priority 1 â&#x20AC;&#x201C; Patient Safety
Elimination of Avoidable Pressure Ulcers
Why is it a Priority?
Pressure ulcers are recognised as a serious problem, having a detrimental effect on patientsâ&#x20AC;&#x2122; health
and well being and are a significant burden to the NHS. It is estimated that the prevalence of
pressure ulcers in hospital settings is around 10.2% (Phillips, Buttery 2009)
A pressure ulcer or bed sore is an area of skin and or underlying tissues which is damaged. This is
due to lying or sitting in one position for too long without moving or by rubbing, dragging or sliding
down or across the bed which can strip the top layers of the skin. Pressure ulcers are most likely to
develop over bony areas. The areas most at risk are the heels, bottom, and base of the spine,
elbows, shoulders and the back of the head.
Pressure ulcers can occur in any patient but are more likely in high risk groups, such as the elderly,
people who are obese, malnourished, or have incontinence problems, those who have impaired
mobility or are immobile and patients who are seriously ill. They are seen as a way of measuring
the safety and quality of care received by patients and the majority of ulcers are avoidable if actions
are put in place. Therefore eliminating avoidable pressure ulcers is our priority.
It is recognised that there are situations where pressure ulcer development is unavoidable and
patients may develop a pressure ulcer in hospital, even though all actions have been taken, for
example patients with critical illness which may prevent them being moved for repositioning, patients
who refuse to be repositioned and patients who are terminally ill and unable to tolerate repositioning
due to their condition, skin failure will exist.
At UHCW the European Pressure Ulcer Advisory Panel grading of pressure ulcer damage is utilised
which identifies 4 grades of pressure ulcers. (See the glossary for the grade definitions)

What we have done already?
At UHCW the prevention of avoidable pressure ulcers has long been a priority which is reflected by
investment in prevention, this included establishment of Tissue Viability Nurses, education,
equipment and implementation of clinical guidelines. However, after an initial significant decrease in
the prevalence of hospital acquired (i.e. patients who develop pressure ulcers whilst in hospital) and
inherited (i.e. patients who are admitted to hospital with pressure ulcers) pressure ulcers had
remained relatively static as indicated by the prevalence audits. Prevalence audits although useful
only provided a snap shot of what was happening on one particular day and do not identify why the
pressure ulcers were occurring and how many of these were avoidable.
In order to identify why ulcers were occurring and how many were avoidable, a number of actions
were put in place. In 2009, pressure ulcers were identified as a key patient safety issue and as part
of UHCW Patient Safety First Strategy a target was set to reduce avoidable hospital acquired
pressure ulcers by 30% over 2 years.
The Trust re-launched a strategy for prevention and
implemented incidence reporting with all pressure ulcers being reported as clinical adverse events
and a root cause analysis on grade 3 and 4 pressure ulcers being undertaken. All reported grade 3
and 4 pressure ulcers are looked at by the tissue viability nurses to confirm that they are pressure
ulcers, to identify where, and why they occurred and to use themes to share learning and to inform
the education of staff.

Our Goal
UHCW has a strong commitment to the delivery of harm free care for patients and to deliver the
Strategic Health Authorityâ&#x20AC;&#x2122;s aspiration to eliminate avoidable grade 2, 3 and 4 pressure ulcers by
December 2012.

Whatâ&#x20AC;&#x2122;s our starting point?
Since the establishment of incidence reporting in 2010, there has been a 41% reduction in the
incidence of avoidable grade 3 and 4 pressure ulcers. In 2010/11 there were 106 patients who were
reported and identified to have hospital acquired avoidable grade 3 and 4 pressure ulcers compared
with 63 patients reported in 2011/12. The graph below shows the number of pressure ulcers
reported each quarter during 2011-2012 and demonstrates a continued reduction and downward
trend in the number of patients who are developing hospital acquired grade 3 and 4 pressure ulcers

The initial focus had been to reduce and eliminate the number of patients developing hospital
acquired grade 3 and 4 pressure ulcers this as now been extended to include grade 2 pressure

36

ulcers. The Tissue Viability Team have developed and delivered a range of education and
awareness sessions to staff aimed at pressure ulcer prevention and with the support of the
communication team have recently launched a communication campaign within UHCW. The initial
goal for all wards is to aim to have 100 days free from patients developing avoidable hospital
acquired pressure ulcers.

How we will achieve our Goal
To achieve our goal we have developed a comprehensive action plan which builds on the work that
we have already implemented to ensure that pressure ulcer prevention is embedded in the
organisation from ward to board and everyone sees pressure ulcer prevention as their responsibility.
This will include:
No

Objective

Action required

Responsibility

Completion
date

1.

To implement
performance
monitoring
framework

•

Chief Nurse

April 2012

2.

To implement
the NHS
Safety
Thermometer
to monitor
the
prevalence of
pressure
ulcers
monthly
To deliver
education
and training
to all groups
of clinical
staff

•

To raise
awareness of
elimination of
pressure
ulcers
To assess
knowledge of
staff in

•

3

5.

6.

•

•

•

•

How will
success be
measured
Minutes of
Pressure Ulcers
will be reported and performance
meetings and
monitored as part
reduction in
of as part of the
number of
performance
monitoring for both pressure ulcers
nursing and
speciality
performance.
Implementation of
NHS Safety
Thermometer to all
wards.
Reporting of data
in accordance with
national CQUIN
requirements

NHS Safety
Thermometer
results available
monthly from all
wards.

Associate
Director of
Nursing (Patient
Safety and
Quality)

March 2013

Pressure Ulcer
awareness to be
introduced into
Trust induction
Power
talks/educational
briefings to be
delivered to staff in
clinical practice
Implementation
100 days free
campaign

75% of front line
clinical staff will
have received
education in
relation to
pressure ulcer
prevention by
March 2013

How we will monitor and report progress
Progress will be monitored through the implementation of the NHS Safety Thermometer which will
be completed one day each month. In addition, the current incident reporting process will continue.
The point prevalence results from the patient safety thermometer and the incidence of avoidable
pressure ulcers will be monitored and discussed at the Speciality Operational Performance Meetings
and the Nursing and Midwifery Quality and Performance meeting.
As part of the monitoring process, performance meetings will also be held with modern matrons and
ward managers following root cause analysis on individual patients to review causation and action
plans. The incidence of pressure ulcers, action plans and progress will be reported to the Patient
Safety Committee quarterly and also to the Care Quality Review Group.
Clinical Lead: Gillian Arblaster – Associate Director of Nursing Education and Research.
Gillian.Arblaster@uhcw.nhs.uk

38

Quality Priority 2 – Clinical Effectiveness
Increasing Effective Discharge
Why is it a Priority?
The maintenance of effective patient flow through UHCW is a vital component in supporting the
Trust to provide high quality patient care, meet required performance targets and maintain financial
competence. Discharge was a Quality Priority for the Trust in the 2009/2010 Quality Account and
although we achieved some success in implementing a variety of actions, the Trust still faces an
ongoing problem with discharging patients effectively that has resulted in the Trust Board including
it again as a focus for this year’s Quality Account.
Two thirds of hospital beds are occupied by older people (National Service Framework for Older
People, Department of Health, 2001). This is due to the ageing nature of the population and the
increased risk of ill health amongst this population
group. Such patients often have multiple complex
medical problems leading to an increased risk of
requiring hospital admission. At the same time changes
to primary health and social care services have led to an
increasingly frail and complex cohort of older people in
hospital with greater medical and social care demands.
Unnecessary prolonged hospital admissions can also
increase the risk of the development of further acute
medical problems, thereby further increasing the
complexity of discharge plans and prolonging the length
of hospital stay.
Previous surveys of the hospital inpatient population
have shown that in the region of 100 patients at any one
time do not need to be in hospital, but do so because of
delays in discharge processes. An inability to maintain
sufficient exit from hospital beds leads to a backlog
effect which has a negative impact, leading to capacity
pressures in A&E and difficulties achieving the national 4 hour wait target. UHCW has for some time
struggled to consistently meet this target and this in turn has a significant adverse impact on the
Trust's ambition to achieve Foundation status.

Ensure that improvements to patient flow and discharge are sustainable in the long term.

How we will achieve our Goal(s)
We will achieve our goals by undertaking a number of important actions. These will include a
number of operational actions and a number of clinical actions.
Operational Actions
• Appointment of a Director of Patient Discharge to provide the required Trust wide clinical
leadership.
• Appointment of a Lead Nurse for Discharge to support the Director of Patient Discharge.
• Identification of "Clinical Champions" in all ward areas to support the work of the Director of
Patient Discharge and Lead Nurse for Discharge.
• Establishment of a Discharge Action Group to oversee and monitor implementation of all
actions relating to improvement of patient flow and discharge.
• Review of current policies, procedures and guidelines relating to discharge ensuring areas of
responsibility are clearly defined across all disciplines.
• Development and implementation of clear guidance on the management of relatives and
carers during the discharge planning process.
• Implementation of robust repatriation processes between UHCW and other referring
hospitals.
• Development of governance processes regarding prolonged length of stay patients and
delayed discharges.
• Undertake collaborative working with external agencies to review and improve supported
discharge processes.
Clinical Actions
• Raising awareness amongst clinical teams through a programme of education, of the
importance of timely discharge planning in relation to high quality patient care and Trust
performance.
• Defining of acceptable standards of care to support discharge processes and to facilitate
performance monitoring.
• Implementation of multidisciplinary working to support robust discharge planning.
• Changing of clinical practice to support an increase in morning discharges by introducing
daily board rounds on all ward areas.
• Identification of internal delays to discharge processes and actions to reduce such delays.
• Development of a roll out plan for the introduction of multidisciplinary working and daily board
rounds on all base wards across UHCW.
All of the above actions are incorporated into a more detailed Discharge Action plan which indicate
timescales and who is responsible for achievement of the actions.

How we will monitor and report progress
Progress against the Discharge Action Plan will be monitored in three ways.
1) Discharge Dashboard
Development of a Discharge Dashboard dataset containing all relevant data regarding patient flow
and discharge, which will be reported and monitored for all base ward areas on a monthly basis.
This will allow monitoring of a number of issues relating to patient flow and discharge.

Target for achievement of milestone
Develop and disseminate discharge criteria for 3
conditions
Implement discharge criteria for above 3 conditions
50% of appropriate patients discharged in accordance
with criteria led discharge
75% of appropriate patients discharged in accordance
with criteria led discharge

Delivery and oversight of the Discharge Action Plan will be undertaken by a Discharge Action Plan
Task and Finish Group, chaired by the Director of Patient Discharge. This group will report to the
Patient Flow Action Group, chaired by the Associate Medical Director for Non elective care.
This group will report to the Delivery Unit, chaired by the Chief Operating Officer. The Delivery Unit
reports to the Chief Operators Group, chaired by the Chief Executive Officer.
Clinical Leads: Director of Discharge and Clinical Director for Care of the Elderly and Acute
Medicine Dr Nicholas Balcombe & Michelle Linnane, Lead Nurse for Discharge

42

Quality Priority 3 - Patient & Staff Experience
Using Real time Patient feedback to affect change
Why is it a Priority?
Our Strategy is to be the best local choice for the people of Coventry and Warwickshire, whilst
becoming a national centre of excellence for research and education, to deliver the outstanding,
innovative services expected by our communities and stakeholders
Clearly having and publishing evidence that shows we can offer the best possible patient experience
is critical to our success, as well as giving us information to quickly identify areas that need
improvement.
The lessons from the review into Mid Staffordshire NHS Foundation Trust has underlined the vital
link between patient and public engagement, patient experience and quality and the risks when the
two are not linked. We are determined that at our Trust these two factors are intrinsically linked,
using a combination of patient
survey information, patient and
staff stories, direct feedback via
our patients, Foundation Trust
members, Patients Council and
our shadow Youth Council,
alongside
information
from
Complaints and our Patient
Advice and Liaison Service. At
UHCW, to strengthen this link,
we merged a number of areas
associated
with
patient
engagement
and
patient
experience
into
a
single
directorate (Engagement) in late
2010 and so are already in a
strong position to take forward
the initiatives being promoted by our Strategic Health Authority Cluster (the Midlands and East
SHA).
Also, in line with the ambitions of the Midlands and East SHA, UHCW is developing a â&#x20AC;&#x153;Patient
Revolutionâ&#x20AC;? strategy with the intention of putting the patient experience at the heart of our work to
support our strategic goal to offer the best possible patient experience. UHCW already has a good
track record in patient experience with a well established real time patient survey (Impressions),
alongside which sits our staff survey (Staff Impressions). Results from this show that 94% of our
patients report a good overall Impression of the Trust.

Our Goal
Our goal is to offer the best possible patient experience with an ultimate aim within our 5 year plan
to be the top performing Trust in the country for Patient Experience.

How we will achieve our Goal
43

We will implement the Net Promoter Score across the Trust starting with in-patients at the beginning
of the year and extending this across the whole Trust during 2012/13. The Net Promoter Score is
derived by asking users of our services the following question;
"How likely is it that you would recommend these services to a friend or family?"
The Net promoter score is the difference between the percentage of users who would recommend our
services minus the percentage of those who would not. A score of +50 or above is considered quite high
(NHS Institute, Score ranges from -100 to +100)
Our baseline score for April 2012 was +44.
By the end of the year we aim to achieve a 10 point improvement in our baseline score.
We also aim to move from surveying 10% of our in-patients at the beginning of the year to surveying
many more of our patients (for whom it is appropriate to request they complete the survey) by the
end of 2012/13. Exactly where this extension will take place will depend on the requirements being
decided on nationally and regionally but early indications are that this will be into Accident and
Emergency as a minimum.
We will then work to achieve continual improvements over the next 5 years to reach our ultimate
aim. This will be achieved by analysing the data as close to real-time as possible and feeding
significant issues and emerging trends to front-line staff so appropriate action can be taken.
We will work with front-line staff to make sure they receive timely reports of the experience of their
patients and will support them in developing and implementing action plans for improvement. Our
Modern Matrons already have access to our Impressions results but during the coming year we will
be developing a system so they will receive alerts when detailed comments about their services are
submitted via the Impressions survey. This will allow us to address issues quickly and recognise
where longer term improvements are needed. This will be overseen by the Trusts Patient
Engagement and Experience Group and will be included in the monthly Patient Experience reports
to the Trust Board.
In the last year we have strengthened our relationship with the Coventry LINk, having Quarterly
meetings with the LINk management and, from April 2012, these meeting also include Warwickshire
LINk. We have also worked with the Coventry LINk on their recent Enter and View activity at the Trust.
We will maintain this relationship during the year as the LINks evolve and HealthWatch emerges.
We will continue to involve our Patientsâ&#x20AC;&#x2122; Council in key areas of work, building on recent activities
and including additional activities such as mystery shopping, job shadowing clinical teams and
conducting cleanliness audits. We will have a programme of events during the year for our Youth
Council members, which will include sessions on our services, their expectations and what we might
do to improve our services for young people.

44

How we will monitor and report progress
Our patient experience work is led and overseen by our Chief Marketing Officer, supported by our
Director of Engagement and her team, alongside our Chief Nursing Officer and the clinical teams
across the Trust. The Trust also has a nominated Non-Executive Director with Patient Experience
within their portfolio and non-executive directors are involved directly in patient experience activities,
such as the patient safety Walkrounds.
We will be monitoring our progress using the Friends and Family Question, promoted in January by
the Prime Minister and adopted across the NHS in the Midlands and East Strategic Health Authority
region. By the end of the year we will be asking 10% of our in-patients and those in A&E how likely
they would be to recommend our service to friends or family, in line with national/regional
requirements. We will be asking this in a number of ways using staff, volunteers, text messaging
and telephone interviews. The results from this, collected in real time and broken down weekly, will
be reported to our Trust Board each month.
We will also report real patient and staff
stories to our Board. This information will be
used to drive our work to continually
improve the experience of our patients,
visitors and staff.
We will also continue to use our Impressions
survey to give us more detailed information
on patientsâ&#x20AC;&#x2122; specific experiences and both
this and the Friends and Family questions
results will be available at ward and
specialty level as well as that for the whole
Trust. We will continue to publish our
Impressions results on our web-site and will
include our Friends and Family question
results as these become available during
the year.
Complaints will also continue to be used as
a key source of information on patient
experience and our current reporting mechanisms around Complaints will continue. All our formal
complaints responses are read and signed by our Chief Executive Officer.
We also monitor digital media sources of feedback including web postings, facebook and twitter
content. This is an area of feedback that we see as an area of expansion and we will be keeping a
close watch on how this develops over the coming year.
Our Trust Board members carry out Patient Safety Walkrounds, talking directly to staff, patients and
carers about their experiences of our care and what they would suggest as improvements. These
suggestions are then taken up directly with those staff that can act on the feedback and make
appropriate improvements. In 2012/13, we intend to add patient environment Walkrounds (including
Estates and linked to the PEAT work) to our patient experience work programme.

45

All the elements of patient experience are reported to senior staff, management and the Trust’s
Leadership through a number of formal committees as well as to the Trust Board. These include:
•
•
•
•
•

Wherever we find our patients are suffering a poor experience, we will work with front-line staff to
put in place action plans to complete necessary remedial work to ensure the patient experience
improves in this respect. This will be overseen by our Patient Engagement and Experience Group,
reported to our Quality Governance Committee and ultimately our Trust Board.
For more information on Patient Experience and Engagement please contact the Lead: Janet
white, Director of Engagement. Janet.White@uhcw.nhs.uk or telephone 024 76967602

46

5.0 Statements from the Trust Board
The following statements offer assurance that UHCW is performing to essential standards,
measuring clinical processes and involved in projects aimed at improving quality. They are also
common to all providers making this account comparable to other NHS Trusts Quality Accounts.

5.1 Review of Services

During 2011/2012 UHCW provided and/or sub contracted 62 NHS services. UHCW has reviewed all
the data available to them on the Quality of Care in 61 of these NHS services.
The income generated by the NHS services reviewed in 2011/2012 represents 95.8% per cent of
the total income generated from the provision of NHS services by UHCW for 2011/202.
*this number represents the number of services as detailed in the Trustâ&#x20AC;&#x2122;s Acute Contract 2011/2012.

5.2 Participation in Clinical Audits
The Department of Health describes 51 national clinical audits which Trusts should consider in their
2011/12 Quality Account.
During 2011/2012 45 national clinical audits and 4 national confidential enquiries covered NHS
services that UHCW provides. During that period UHCW participated in 91% of national clinical
audits and 100 % of national confidential enquiries of which it was eligible to participate in.
The national clinical audits and national confidential enquiries that UHCW was eligible to participate
in during 2011/2012 are listed in the table below. The national clinical audits and national
confidential enquiries that UHCW participated in, and for which data collection was completed during
2011/2012 are listed below indicated with a green tick, alongside the number of cases submitted to
each audit or enquiry as a percentage of the number of cases required by the terms of that audit or
enquiry in column three. The CQUIN supplement details those audits which UHCW were eligible to
take part in but did not and the rationale for non-participation.
Eligible audits applicable to UHCW as published in the
Department of Healthâ&#x20AC;&#x2122;s Quality Account List

No qualifying
cases but
UHCW
participated in
organisational
component of
audit
100%

NCEPOD Bariatric Surgery

49

%
participation
2011/2012

100
100

100

100
100
100

97

100

No qualifying
cases but
UHCW
participated in
organisational

Eligible audits applicable to UHCW as published in the
Department of Healthâ&#x20AC;&#x2122;s Quality Account List

NCEPOD Cardiac Arrest Study

Did UHCW
participate
(submit data) in
2011/2012

%
participation
2011/2012
component of
audit
100%

UHCW has investigated why participation was lower than expected in the audits that have been
starred. Explanations can be found in the Clinical Audit and Effectiveness Supplement.
The reports of 23 National clinical audits were reviewed by UHCW in 2011/2012 and the reports of
94 Local (not national) clinical audits were reviewed by UHCW in 2011/2012. A brief summary of
some of the key actions we have taken to improve the quality of healthcare is provided in an
additional Clinical Audit and Effectiveness Supplement which can be found on our website or on
request.
For more information on National or Local Clinical Audit please contact the Quality and Effectiveness
Department on 02476 968282

5.3 Participation in Clinical Research
Research is an integral component of providing world-leading excellence in clinical care. It enables
UHCW NHS Trust to lead innovation and development which enables us to provide the highest
quality patient care. It ensures that we are a leader rather than a follower in healthcare provision
and allows us to attract and maintain highly skilled and motivated staff. We are committed to
establishing our Trust as an internationally recognised centre of excellence through supporting our
staff, working in world class facilities and conducting leading edge research focused on the needs of
our patients.
With over 300 ongoing research projects led by 200 staff across a wide range of specialities, our
patients are given many opportunities to take part in research. The number of patients receiving
NHS services provided or subcontracted by UHCW in 2011/2012 that were recruited during that
period to participate in research approved by a research ethics committee was 2,513.
Our current major research themes are metabolic and cardiovascular medicine, reproductive health,
musculoskeletal and orthopaedics and cancer. These are complemented by additional areas of
clinical research activity (for example stroke and respiratory medicine). Research activity continues
to increase. There are over 50 research nurses, midwives and allied health professionals assisting
with research projects and increasing numbers of staff are undertaking research, higher degrees
and PhDs. The Trust provides free research training for all staff. This increasing level of
participation in clinical research demonstrates UHCW NHS Trustâ&#x20AC;&#x2122;s commitment to improving the
quality of care we offer and to making our contribution to wider health improvement.
This year, we have increased research income from external grants and commercial companies and
increased our number of Professorial posts to provide academic leadership. We hosted a

50

successful Medicines and Healthcare products Regulatory Authority (MHRA) inspection of our
research governance processes for drug trials in June 2011. Our R&D team was shortlisted for a
national Health Services Journal award for ‘Improving the Research Culture’. In 2011-12, we
opened our Human Metabolism Research Unit, a custom built world class facility designed to
measure and analyse all facets of how we create and use energy. Knowledge of an individual’s
energy expenditure in such detail will allow new avenues of metabolic research with the potential to
develop new treatments and drugs; it is further envisaged that the Unit will uncover new
relationships between diet, life-style and long term health implications in the population at large.
In the last three years, over 500 publications have resulted from our involvement in research,
helping to improve patient outcomes and experience across the NHS.
The Trust’s mission, Care – Achieve – Innovate, is explicit in that we will deliver the best care for our
patients, achieve excellence in education and teaching and innovate through research and learning.
As such, we have a clear strategy to develop research and innovation. The key areas for delivery
are to ‘instil and embed a culture of research and innovation’ and ‘grow investment in, and revenue
from, research and innovation’. By delivering on our research and innovation strategy, we also
contribute to the delivery of the other Trust strategic priorities.
For a list of all the publication Titles please contact Library and Knowledge Services on 02476
968827

5.4 Goals Agreed with Commissioners

A proportion of UHCW’s income in 2011/2012 was conditional on achieving quality improvement and
innovation goals agreed between UHCW and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services through the Commissioning for
Quality and Innovation payment framework. Further details of the agreed goals and performance for
2011/2012 are detailed in the CQUIN Supplement. Detail of the 2012/2013 CQUIN goals are also
provided in the supplement located on the UHCW website at www.uhcw.nhs.uk or by contacting the
Quality and Effectiveness Department, 02476 968282.

5.5 Care Quality Commission
UHCW is required to register with the Care Quality Commission and its current registration status is
Registered (without any compliance conditions) and licensed to provide services.
The Care Quality Commission has not taken any enforcement or compliance action against UHCW
during 2011/2012.
The CQC completed an unannounced inspection at UHCW on 28th December 2011 around patient
care and staffing levels in the Emergency Department. The team of inspectors completed
observational and process reviews, along with staff and patient interviews. The CQC were very
positive about their findings and did not place any actions on the Trust
A further unannounced inspection was completed on 20th / 23rd March 2012, around documentary
compliance with the Abortion Act 1967 (amended) for termination of pregnancies. The CQC have

51

issued the final report which confirmed UHCW’s compliance with the relevant sections of the Act.
This will be shared on the Trust’s Internet site, with all published CQC inspection / compliance
reports.
UHCW also participated in a planned CQC review during November 2011. This was part of a joint
CQC / Ofsted Inspection of Safeguarding and Looked after Children’s Services across
Warwickshire. UHCW were included in the review due to the services provided at Rugby St Cross,
as one of the partner organisations and healthcare providers in the wider Warwickshire Health
Economy.
In September 2011, the Imperial College, London, also informed the CQC regarding a mortality
outlier for “Septicaemia – except in labour”. UHCW completed an internal review, the results of
which were notified to the CQC with no further actions required by the Trust.

5.6 Data Quality
Data quality is encompassed within many requirements of the Information Governance Toolkit of
which the Trust is meeting the required attainment levels. The data quality team provide regular
training to users who collect and record patient data which supports patient care and data
submissions.
External data quality reports are reviewed and appropriate actions are taken to address areas of
concern. In addition, internal data quality reports and performance dashboards are in place to
provide the Trust with an overall view of the quality of data also highlighting areas for improvement.
UHCW submitted records from April 2011 to December 2011 to the Secondary Uses Service for
inclusion in the Hospital Episode Statistics which are included in the latest published data. The
percentage of records in the published data: which included the patient’s valid NHS number was:
99.2% for admitted patient care;
99.6% for outpatient care; and
97.3% for accident and emergency care
Which included the patient’s valid General Medical Practice Code was:
100% for admitted patient care;
100% for outpatient care; and
100% for accident and emergency care

5.8 Clinical Coding Error Rate
UHCW was not subject to the Payment by results clinical coding audit during 2011/2012 by the
Audit Commission UHCW commissioned an external audit of 200 case records in December
2011 and the error rates for diagnoses and treatment coding (clinical coding) were:
• Primary Diagnoses incorrect
8.5 %
• Secondary Diagnosis incorrect
7.3 %
• Primary Procedures incorrect
6.2 %
• Secondary procedures incorrect
2.0 %
UHCW will be taking the following actions to improve data quality;
The Trust has been working with an external contractor in an effort to improve the quality and
depth of information which is available for clinical coding purposes. A process change has also
been implemented so that if earlier finished consultant episodes need to be coded at month
end prior to the patient’s discharge, the coding of the whole spell is reviewed once a discharge
letter is available and/or the health record have been reviewed by the clinical coder.

53

6.0 Statements from Primary Care Trusts, Local Involvement
Networks and Overview and Scrutiny Committees
The Arden Cluster
The Arden Cluster (comprising of NHS Coventry and NHS Warwickshire), in its’ role as
Lead Commissioner in respect of services delivered by the University Hospitals Coventry
and Warwickshire NHS Trust (UHCW), is pleased to review and to comment on this
Quality Account.
The version seen by the Arden Cluster was labelled draft and was incomplete and
therefore we are unable to verify the contents as requested.
We are disappointed that the account from the patients/carers and public perspective
appears too business orientated and is difficult to navigate. The account does not
sufficiently reflect the patient orientated outcomes and/or service improvements which we
have seen through our routine monitoring of the Trust. As a result, this account fails to
inform the public of the changes that have been made or are required in next year’s
priorities.
The impact to front line care is not demonstrable from the examples given and the
account is missing key aspects of clinical care such as Infection Control, the learning
there has been from Serious Incidents and workforce/staffing. More evidence within key
sections such as Never Events, Mortality and the Trust Board Patient Safety
Walkarounds on how the Trust is taking action would provide the public with greater
assurance of the quality of care. In addition the account could have been strengthened
with the use of case studies.
We do not feel the account fully reflects the wide range of quality improvements that the
Trust have implemented within the year, as highlighted in monthly contractual quality
meetings. Examples being the roll out of nurse led discharge, the development of
ambulatory care pathways to allow patients to be cared for in their home environment
and matching prescribing of medication to what can be prescribed in primary care.
We found it difficult to understand what difference users and carers would see in their
experience of care as a result of the work undertaken for last years’ priorities. Also
where performance has either not improved or has failed such as the A & E four hour
wait, delayed transfers of care and patient experience (national In-patient survey), the
account fails to show the resulting changes or improvements required.
The priorities for the Trust for 2012/13 reflect regional and national quality priorities that
have been set and agreed by the Arden Cluster. We have had evidence in year of how
quality is a key theme throughout all of the strategic developments of the organisation;
this is not reflected within this account.
We have seen significant work to reduce patient falls, pressure sores and improvements
to meet infection control targets. These continue to challenge all our health care
organisations for the coming year, especially with the regional aim of eradicating
attributable pressure sores in all health care organisations. UHCW have set targets for
2012/13 to meet this challenge.

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We expect to see significant improvement in the coming year relating to meeting A&E
targets and improved discharge of patients that can be sustained.
The Arden Cluster have continued to work in partnership with UHCW throughout the year
to ensure that service users, carers and their families receive excellent care and
treatment throughout their healthcare experience.
As commissioners we support UHCW’s commitment to delivering safe services of a high
quality standard and further improving the patient’s experience.
UHCW Response:
UHCW would like to thank the Arden Cluster for their useful commentary and would like
to take the opportunity to respond to some of the points raised.
Due to the date of April 30th being given by the Department of Health as a deadline for 3rd
parties to receive the Quality Account for comment, UHCW communicated early in the
Account production process that the draft they receive would be a working draft as the
Trust had until the beginning of June to continue to finalise sections of the document.
Third parties were also informed early that due to internal data validation processes
some data would be unable to be circulated in the draft Account. Commissioner
colleagues have access to our data on a monthly basis and would be able to use their
knowledge of our performance to help inform their commentary.
Since the first Quality Account was produced in 2009/2010 UHCW has used the same
template to present the content. This has been cited by the West Midlands quality
Observatory (WMQI) as good practice, and both the Warwickshire LINk and Coventry
LINk have noted its readability and user friendliness. The Department of Health Quality
Account Toolkit and the WMQI give strong guidance on the content of a Quality Account.
UHCW has been guided by this in the production of this year’s account. Writing a
readable and navigable document that it is not overloaded with information is a challenge
and UHCW strive to achieve a balance of patient orientated outcomes and service
improvements. UHCW believe it has included, based on past experience and feedback,
what our patients and service users would like to read about.
The Trust makes numerous quality improvements within the year, to many to list them all
within the Quality Account. The content included in the 2011/2012 Account has been
approved by UHCWs Trust Board as appropriate information on the quality of services
UHCW provides. This year UHCW will launch a Quality page on its website which we can
use to publish more information on service and quality improvements. UHCW would
welcome an earlier discussion with Commissioner colleagues about which quality
Improvements they would like to see reflected in 2012/2013 Quality Account.
The 2010/2011 Quality Account included a section on nurse led discharge.
UHCW recognises and states at the beginning of the Account that last year’s priorities
had a mixture of qualitative and quantitative measures where the goals were not always
measurable making it difficult to demonstrate the benefits for patients. UHCW hope this
year’s priorities are much clearer in terms of measurable benefits.
Regarding where improvements are required to enhance failing targets, advice from the
WMQI is to signpost the reader to a member of staff or additional information rather than
include in the Account. UHCW have adopted this approach by stating for more
information contact our Head of Performance Management.

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The Health, Social Care and Welfare Reform Scrutiny Board (5) of
Coventry City Council
The Health, Social Care and Welfare Reform Scrutiny Board (5) of Coventry City Council
welcomes the opportunity to comment on the draft 2011/12 Quality Account of the
University Hospitals Coventry and Warwickshire NHS Trust (UHCW). The Board briefly
considered the draft Quality Account during May and June 2011 and wish the following
points to be noted:
The Board welcomes the progress made by the Trust on the 2010/11 Quality Account
priorities demonstrated by this yearâ&#x20AC;&#x2122;s document. In particular the Board welcomes the
opening of the Forget Me Not Lounge and Memory Lane as demonstrable achievements
reflecting the increased focus on dementia awareness. With regards to the management
of sepsis and added emphasis on nutritional management the Board notes that not all of
the work expected last year has been completed to schedule.
Generally progress against clinical indicators is positive, and the Board was pleased to
note the improved Hospital Standardised Mortality Rates reported in the Quality Account.
This yearâ&#x20AC;&#x2122;s Quality Account also includes the requested comparative and trend data
which further illustrates this information. The one area of concern that the Scrutiny Board
has regards the regular failure of the Trust to meet the target of 95% of patients
presenting at A&E to be seen within 4 hours. This is not the first time that UHCW has
reported problems in this area, and whilst the Board notes the responsibility of the wider
health economy to halt the continued rise in attendance at the Walsgrave site,
performance is unacceptable. At the earliest convenience the Board will be using its
powers to request that the Trust present its plans for moving to a position where it is able
to consistently meet its obligations to local patients.
The Board welcomes the selection by the Trust of; the elimination of pressure ulcers,
increasing effective discharge and using real time feedback to effect change.
Members are pleased to note the emphasis placed by the Trust on patient experience
and feedback. The section on patient feedback and complaints etc is more
comprehensive than previously and should support the Trust in continually improving the
patient experience. Work on eliminating pressure ulcers is welcomed as this reflects the
wider emphasis within the wider health economy on pressure sores and the Board would
encourage the Trust to ensure that its work is spread as wide as possible encouraging all
stakeholders to learn from progress in this area. The return of effective discharge to the
Trustâ&#x20AC;&#x2122;s Quality Account priorities is also supported given the importance of this area in
ensuring particularly elderly patients needs are met. The Board welcomes the
appointment of a Director of Patient Discharge and a Lead Nurse for Discharge and
looks forward to continued joint work with the City Council and other stakeholders in
ensuring that patients are able to return home and be able to live independently.
Whilst welcoming as above the continued emphasis on the elimination of pressure ulcers
the Board was disappointed last year to find that there was a lack of clarity around the
data for pressure ulcer identification between different drafts of the report. The Board
notes that this year the Trust has simplified its process and provided clearer data.

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The Board welcomes the developments over the past year in amendments to the parking
arrangements at the Walsgrave site. Whilst this issue should not distract from the clinical
priorities of the Trust it is a matter which concerns many patients and can be a factor in
patient experience as a result of this. The modifications to the charging regime are
positive and in general terms the plans to expand the number of spaces available on site
are welcomed.
The development of the Walsgrave site as a Major Trauma Centre are also something
the Scrutiny Board welcomes, and the Board was pleased to be able to offer its support
to this proposal during the SHAs consultation period.
The timetable and process for local authorities such as Coventry to participate in Quality
Accounts is particularly inconvenient (falling over the election period and subsequent
annual general meeting period) and the Scrutiny Board would have preferred to have
played a fuller role in the development of the Quality Account, however this is a national
timetable and outside UHCW control. However the earlier Members are able to engage
in a future dialogue regarding the priorities in the Quality Account the more meaningful
will be the contribution of the Scrutiny Board.
Finally the Board would like to express its thanks to UHCW for the support it provides to
the Scrutiny Board, and for responding to queries and requests for information promptly
and efficiently. The Board are anticipating holding a Scrutiny Board meeting at the
hospital site during the 2012/13 municipal year to discuss current issues including local
developments of maternity and paediatric services and the progress on achieving the
Quality Account priorities.
UHCW Response:
UHCW would like to thank the Coventry City Council Scrutiny Board for their useful
commentary and would like to take the opportunity to respond to the point raised around
the A&E 4 hour target.
UHCW manages an extremely busy A&E service including major trauma and we have
we have been experiencing significantly higher numbers of attendances with patients
who are acutely ill.
However we would highlight that this does not mean that patients are not receiving good
care. The CQC performed an unannounced visit to our Emergency Department in
December 28, 2011 specifically looking at the care and welfare of people who use the
service and staffing. For both aspects we were found to be compliant.
In fact the CQC found that people attending the Emergency Department received care
and support in a safe and timely manner and their dignity and privacy was respected.
They also observed nursing staff explaining treatment decisions to people at a level and
pace that enabled them to understand and observed a nurse responding sensitively to
person who was agitated and confused about what was happening.
Comments from our patients during the inspection included:
• "Staff are very good – they have been very polite, they listened to me and I could see
they were interested in their work.”
•”'The doctor took the time to explain what had happened and what was wrong. The
doctor spoke to my son and not to me – I was very impressed with this."

57

Nevertheless we are doing a lot of work around why at certain times we experience
significantly high attendances and unacceptable delays for admitted patients. It would
appear that there is a system-wide issue and it is clear that improving patient flow is
critical. We are working very closely with our PCT partners to implement a discharge
focused action plan aimed at reducing bed blockages in other parts of the system which
are preventing patients in the Emergency Department being dealt with in a timely
manner.
As well as this we have introduced a discharge team with a lead consultant and nurse as
detailed in Section 4 of the Quality Account.

Coventry LINk
Coventry LINk’s comments on this Quality Account
Coventry LINk welcomes the role all LINks have of providing commentary on the quality
of services within local Trusts. Coventry LINk has commented upon draft 2.3 of the
Trusts Quality Account. Some of the sections were not completed and some data was
awaited. The Trust has responded to some of the comments below and amended/added
to the document.
Priorities for last year
The Trust has been working to improve quality in 3 areas: management of sepsis,
nutritional management and raising awareness of dementia.
Management of sepsis: there are some areas where progress has not been made or is
still under review so we hope to hear about them in next year’s Quality Account. Further
detail of the level of compliance shown by the audit of administration of antibiotics would
have been useful along with details of whether a future audit will take place.
Nutritional management: the “Eatwell menu” is behind schedule for completion and the
audit for central line infection rates final results are not available. We hope an update will
be included in next year’s Quality Account. LINk is aware that the Trust is recruiting
volunteers to help patients at mealtimes and hopes that more relatives can also visit at
mealtimes to help ensure patients are fed.
Dementia awareness: we are pleased that the Forget Me Not Lounge and Memory
Lane are complete and opened in December 2011 (August 2011 was given as the
completion date in the previous Quality Account). It would have been good if pictures and
a more detailed description were included, along with details of usage.
Regarding the development of NVQ level training around dementia awareness we hope
the Trust has plans in place to ensure that knowledge and course development does not
rely on the one nurse undertaking a MSc in Dementia Care in case there is a change in
her circumstances.
This account reports that 2000 staff have been trained on Dementia and Delirium
awareness. This is the same figure that was reported the previous year, yet this is a
rolling programme of training so we are unclear whether this is an error in the draft or
whether any further staff have been trained.
This year outpatient booking and access to the hospital site including car parking have
been on Coventry LINk’s programme of work. LINk was disappointed not to be given the
opportunity to feed into the Trust’s review of the outpatient letter template. LINk wanted
to input comments we had collected through previous work.

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LINk carried out an ‘Enter and View Visit ‘to complete 641 surveys with patients and
visitors and observations regarding access to the Coventry site. Our recommendations
present an opportunity for UHCW to work with us and hope that LINk can contribute to
the Trust’s car parking group. LINk notes that 883 fewer PALs enquiries were dealt with
in the last year than the previous year and wonders why this was. The clinical coding
error rate needs more explanation and the separate CQUIN section would have
benefitted from an introductory explanatory paragraph.
Priorities for the coming year
We are pleased that the Trust has recognised that previous information has not
necessarily enabled readers to measure the progress on the quality priorities effectively.
The Trust has aimed to provide baseline data and targets as requested by Coventry LINk
and Warwickshire LINk.
The Trust has set 3 priority areas: elimination of avoidable pressure ulcers; increasing
effective discharge and patient and staff experience: real time feedback.
The local priorities table shows the target against Pressure Ulcer Point Prevalence as not
performing against the target, but there is no indicator of what percentage the Trust
should be aiming for. As this is one of the priorities it would be useful to have this
information. Such information is included for discharge (“Delayed Transfers of care”) the
target is 4% and UHCW are achieving 5.5% so there is a clear indication of a target
figure.
We welcome Increasing Effective Discharge as an outcome. LINk has previously
carried out work to review discharge procedures, and this year has fed into the design of
a discharge leaflet and checklist. We understand that there is already a Director of
Patient Discharge, a Lead Nurse for Discharge, multidisciplinary team meetings and daily
board rounds on 3 wards so believe that the CQUIN targets are achievable. We would
like to see quality of patient experience as an additional goal, along with the appropriate
involvement of relatives and carers. We also suggest an additional measure of
monitoring the number of discharges, which take place late in the day (after 8 pm) to
ensure improvement.
Patient experience work is essential. We note in this year’s report the Trust reports a
bigger sample for its Impressions Survey and we hope that this can be built on further in
the coming year. Within priority 3 there are no measurable targets and benefits listed for
work to develop patient experience work. Therefore the detail is unclear as is the impact
the work is going to make in terms of benefits for patients. It is unclear how progress is
going to be reported in next year’s Quality Account.
There were several gaps in the information provided in the draft Quality Account that
LINk received to use for drafting its commentary: for example it was disappointing that
the figures for 18 week wait targets etc were not included. This made drafting our
commentary more difficult. Coventry LINk and Warwickshire LINk organised a meeting
to receive an update on quality account progress in January 2012 and LINk found this
useful. We hope that this can be a building block for further dialogue around quality in the
coming year.
UHCW Response
UHCW thanks the Coventry LINk for their useful commentary and would like to take the
opportunity to respond to some of the points raised.

59

The dementia lounge and memory lane were completed on time and opened at the
beginning of September 2011; they were not officially opened however until December
2011 by the Lord Mayor to coincide with a large regional Dementia Conference that
UHCW was hosting. To avoid confusion this has been made clear in the 2010/2011
progress against quality priorities section. UHCW will place pictures of the Dementia
Lounge and Memory lane on our website for people to view.
UHCW is looking into delivering alternative methods of training rather than the dated
NVQ style of education. The Account has been amended to reflect this.
The 2000 staff training figure was an error in the draft. The correct figure of over 4200
now been placed in the Quality Account.
UHCW has included an explanation as to why PALS figures for 2011/2012 were lower
than 2010/2011.
A further explanation around actions to improve coding rates has been included.
UHCW has included a target regarding pressure ulcer point prevalence in the local
priorities section
UHCW has included the suggested measures in the Increasing Effective Discharge
Priority.
UHCW believes that the Patient Experience Priority does have measurable targets
included, such as improving the NPS score by 10 points. A baseline figure is now
provided in the Account, which wasnâ&#x20AC;&#x2122;t available at the end of April when the version the
LINk received was sent out. The Priority also does describe the benefits of implementing
a more timelier reporting mechanism for staff, using social media and complaints to give
us a richer picture of satisfaction which is discussed at a high level and at ward and
specialty level to drive improvements.
With regards to gaps in data in the draft Account, the LINk received information from
UHCW early on in the Quality Account Production process that stated that UHCW would
not be in a position to share any data until an internal validation process had occurred.
UHCW welcomes further interaction and discussion with the Coventry LINk in 2012/2013
in preparation for next yearâ&#x20AC;&#x2122;s Account.

Warwickshire County Council - Adult Social Care and Health Overview and
Scrutiny Committee
A Task and Finish Group of the Adult Social Care and Health Overview and Scrutiny
Committee considered the draft Quality Account of the South Warwickshire Foundation
Trust on 24 April 2012.
The Adult Social Care and Health Overview and Scrutiny Committee held a special
meeting on 24 May 2012 to consider Quality Accounts. At that meeting they agreed the
points made by the Task and Finish Group in relation to the Quality Account for
University Hospitals Coventry and Warwickshire as set out below.
The Committee welcomed the changes that had been made to the Quality Accounts
following the meeting with the Task and Finish, which are included in italics below.
The committee would wish the following points noted.

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•

The task and finish group felt that the document was well presented and
encouraged the use of visual aids such as ticks and crosses for ease of
reference.

•

Members agreed the three priorities chosen for the next year, and in particular the
continued focus on pressure ulcers. The group agreed that the Quality Account
should include:
the grade of pressure ulcer being recorded
a clear distinction between inherited and hospital acquired pressure
ulcer
an indication of successful treatments – split between inherited and
hospital acquired.

•

The priority for 2012/13 – “Clinical Effectiveness – Effective Discharge from
Hospital” sat well with the work of Warwickshire County Council in developing
community care and virtual wards, and helping people to maintain their
independence.

•

Members acknowledged the work carried out by UHCW to involve patients, the
public and staff. They were however, disappointed that the results of the staff
survey were not included in the draft quality account again this year and referred
to their comments in 2011 that the results of the staff survey were “key to our
understanding of the relationship between the Trust and its staff. It is understood
that the results will be included in the final version but it would help if in the future
the timing of the staff survey was changed to ensure that earlier drafts include the
results”.

•

The task and finish group welcomed the inclusion of trend and benchmarking
data, although the draft Quality Account did not include any detailed information
yet. The group agreed that there should also be clear narrative to indicate where
there had been improvement.

•

The sample for inpatient surveys was small. The group felt that the final Quality
Account should include actual numbers of patients over the year and actual
numbers of patients taking part in the survey.

•

Members felt strongly that there needed to be a reference to access to UHCW
included in the Quality Account as this had a negative impact on patients and
relatives and was an issue raised consistently by elected members, patients and
relatives, constituents and in-patient feedback.

•

Members agreed that there needed to be an addition under the “We Care” section
on bed occupancy in order to evidence any impacts of the closure of Birch Ward
at Rugby St Cross in December 2011.

•

Members agreed that the Quality Accounts should be expanded to include more
outcomes to demonstrate the benefits of the work and improvements carried out
by UHCW.

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•

The group were impressed at the scale of research that had been undertaken and
felt that it would be useful to expand this with some detail of the research
undertaken.

•

Members welcomed the continued work that the Trust has undertaken around
dementia and highlighted this as an area for further reporting to the HOSC
outside of the Quality Accounts process.

•

Members highlighted the usefulness of the Quality Accounts for HOSC to identify
areas for further scrutiny.

Councillor Les Caborn
Chair
UHCW Response:
UHCW would like to thank the Warwickshire County Council Adult Social Care and
Health overview and Scrutiny Committee for their useful commentary and would like to
take the opportunity to respond to some of the points raised.
Bullet point 2 – The account has been updated to make clear that all grades of pressure
ulcer are being recorded. Definitions of inherited and hospital acquired pressure ulcers
have been included in the glossary.
Bullet point 4 – UHCW cannot change the timing of the national staff survey results. This
survey is co-ordinated by the CQC. With regards to gaps in information the LINk received
information from UHCW early on in the Quality Account Production process that stated
that UHCW would not be in a position to share any data until an internal validation
process had occurred.
Bullet point 6 - Actual number of responses to the national surveys is included in the
Quality Account.
Bullet point 7 – UHCW has included a section in the Account to detail actions the Trust
has taken to improve car parking and access.
Bullet point 8 - An additional section on the closure of Birch Ward has been included.
Bullet point 10 – The Trust makes numerous quality improvements within the year, to
many to list them all within the Quality Account. The content included in the 2011/2012
Account has been approved by UHCWs Trust Board as appropriate information on the
quality of services UHCW provides. This year UHCW will launch a Quality page on its
website which we can use to publish more information on service and quality
improvements. UHCW would welcome an earlier discussion with colleagues about which
quality Improvements they would like to see reflected in 2012/2013 Quality Account.
Bullet point 11 - UHCW is very proud of the work we have undertaken around Dementia
and dementia awareness and would be happy to report to the HOSC on this topic
specifically.
UHCW welcomes further interaction and discussion with the Coventry LINk in 2012/2013
in preparation for next year’s Account.

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Warwickshire LINk
Warwickshire LINk welcomes the opportunity all LINks have of providing commentary on
the quality of services within local Trusts.
Due to staff changes and the extremely challenging landscape that the Health Economy
has experienced this year engagement and dialogue between UHCW and Warwickshire
LINk has not been as regular or sustained as either partner would want or expect in order
to inform a thoughtful commentary to these Quality Accounts. As a result this
commentary will be brief and only comment on the areas where Warwickshire LINk feels
it has a contribution to make.
Closure of Birch Ward at St Cross Hospital Rugby â&#x20AC;&#x201C; we would have liked more
information shown about this event in the account, but would also like to point out that
this closure was undertaken without any consultation with interested parties or the public
at large.
Warwickshire LINk also notes the inclusion of patients to relate their experiences at the
Board meetings and would be interested to know how this then informs changes or
decisions going forward.
Warwickshire LINk also welcomes Increasing Effective Discharge as an outcome as
the emphasis on discharge and the attendant issues as this is something that our
members tell us impacts on them consistently in a negative way.
Warwickshire LINk and Coventry LINk organised a meeting to receive an update on
quality account progress in January 2012 and LINk found this useful. We hope that this
can be a building block for further dialogue around quality in the coming year.
Warwickshire LINk will also be working with Warwickshire Health and Social Care
Overview and Scrutiny Committee to bring a joint approach to this work.
UHCW Response:
UHCW would like to thank the Warwickshire LINk for their useful commentary and would
like to take the opportunity to respond to the point raised about the closure of Birch Ward.
In September 2010, the Trust opened an additional ward on the St Cross site with the
transfer of Ward 1 of University Hospital to Oak Ward. Ultimately the beds on Ward 1 did
not close as a result of this change and the Trust has operated with an additional 24
beds in its bed stock.
Given the difficult financial pressures facing the NHS and the ÂŁ8m overspend the Trust
found itself in, the leadership team at University Hospitals Coventry and Warwickshire
NHS Trust had to make difficult decisions.
To this end the Trust decided to close 22 beds on the Birch Ward at the Hospital of St
Cross, Rugby from 30 November 2011.
The Trust is aware of the duty outlined in Section 242 of the consolidated NHS Act 2006
which applies if implementation of the proposal, or a decision (if made), would have
impact on a) the manner in which the services are delivered to users of those services, or
b) the range of health services available to those users.
There are a number of reasons why this closure does not fall under this remit:

63

•

•

•

The closure is proposed to be temporary and not a permanent decommissioning
of the clinical area in so far as it reflects decreasing referrals and demand.
However should other pressures for example winter flu pressures increase
referrals then the option will be available to flex it up.
Consideration has been given to closing a ward on the University Hospital site.
However due to the high volume of sick patients attending this site from across
Coventry and Warwickshire and nationally for specialist services, there is a
greater demand for medical beds there. It has also become increasingly difficult
to repatriate the appropriate patients from University Hospital to St Cross and as
such there are often empty medical beds overnight on the St Cross site.
Referrals to the Trust are reducing and therefore the decision makes us more in
line with our patient activity.

As a result of these the Trust feels the decision to close Birch Ward is not a service
redesign or reconfiguration and as such does not fall under the remit of Section 242.
The Trust understands the concerns raised by residents of Rugby and takes pride in the
fact that the local population feels such strong ties to their local hospital. The NHS is
facing a number of challenges at the moment but it has never been the intention of the
Trust to close the Hospital of St Cross.
In fact we have given significant investment to the hospital:
•
•

•

The Trust has proudly opened a £2million state-of-the art Macular Unit at the
Hospital of St Cross.
The first hip operation of its kind in Europe took place at the Hospital of St Cross,
using a new instrument that could revolutionise how surgeons perform one of the
most common types of operations in the NHS.
The Cardiac Rehabilitation Unit at the Hospital of St Cross received praise at a
Parliamentary reception at the House of Commons for the British Heart
Foundation.

We would reiterate that the Hospital of St Cross provides a number of services which are
crucial to the Trust and the people of Rugby including:
•
•
•
•
•

UHCW welcomes further interaction and discussion with the Warwickshire LINk in
2012/2013 in preparation for next year’s Account.

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7.0 Directors’ Statement of Responsibility
The directors are required under the Health Act 2009 to prepare a Quality Account for
each financial year. The Department of Health has issued guidance on the form and
content of annual Quality Accounts (which incorporates the legal requirements in the
Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010
(as amended by the National Health Service (Quality Accounts) Amendment Regulations
2011).
In preparing the Quality Account, directors are required to take steps to satisfy
themselves that:
• the Quality Accounts presents a balanced picture of the Trust’s performance over the
period covered;
• the performance information reported in the Quality Account is reliable and accurate;
• there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
• the data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and
• the Quality Account has been prepared in accordance with Department of Health
guidance.
The directors confirm to the best of their knowledge and belief they have complied with
the above requirements in preparing the Quality Account.
By order of the Board
NB: sign and date in any colour ink except black

65

8.0 External Auditors Limited Assurance Report
INDEPENDENT AUDITOR’S LIMITED ASSURANCE REPORT TO THE DIRECTORS
OF UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST ON
THE ANNUAL QUALITY ACCOUNT
We are required by the Audit Commission under section 5(1)(e) of the Audit Commission
Act 1998 (the Act) to perform an independent assurance engagement in respect of the
compliance Of University Hospitals Coventry and Warwickshire NHS Trust’s Quality
Account for the year ended 31 March 2012 (the “Quality Account”) with the National
Health Service (Quality Account) Regulations 2010 and the National Health Service
(Quality Account) Amendment Regulations 2011 (together, the “Regulations”).
Scope and subject matter
NHS trusts are required by section 8 of the Health Act 2009 to publish a Quality Account
which must include prescribed information set out in the Regulations.
Respective responsibilities of Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Account
in accordance with the criteria set out in Regulation 4 and guidance issued by the
Department of Health on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
Our responsibility is to form a conclusion, based on our limited assurance procedures, on
whether anything has come to our attention that causes us to believe that the Quality
Account does not include the matters required to be reported on as specified in
Regulation 4.
We read the Quality Account and conclude whether it addresses the content
requirements of the Regulations and to consider the implications for our report if we
become aware of any omissions.
We are in compliance with the applicable independence and competency requirements
of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics.
This report, including the conclusion, has been prepared solely for Directors of University
Hospitals Coventry and Warwickshire NHS Trust as a body in accordance with Part II of
the Audit Commission Act 1998 and for no other purpose, as set out in paragraph 45 of
the Statement of Responsibilities of Auditors and Audited Bodies published by the Audit
Commission in March 2010. To the fullest extent permitted by law, we do not accept or
assume responsibility for any other purpose or to any other person for our work or this
report save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with the NHS Quality
Accounts Auditor Guidance 2011/12 issued by the Audit Commission on 16 April 2012.
Our limited assurance procedures included:
−

making enquiries of management;

66

â&#x2C6;&#x2019;
â&#x2C6;&#x2019;

reading the documents; and
comparing the content of the Quality Account to the requirements of the
Regulations.

A limited assurance engagement is narrower in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance
engagement.
Limitations
The scope of our assurance work did not include consideration of the accuracy of the
reported indicators, the content of the quality account or the underlying data from which it
is derived.
Non-financial performance information is subject to more inherent limitations than
financial information, given the characteristics of the subject matter and the methods
used for determining such information. It is important to read the Quality Account in the
context of the criteria set out in the Regulations.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us
to believe that the Quality Account for the year ended 31 March 2012 does not
incorporate the matters required to be reported on as set out in Regulation 4.

9.0 Providing Feedback
Your Views, Your Involvement
Thank you for taking the time to read UHCWâ&#x20AC;&#x2122;s annual Quality Account. We hope you
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Glossary
Acute Trust
A Trust is an NHS organisation responsible for providing a group of healthcare
services. An acute Trust provides hospital services (but not mental health hospital
services, which are provided by a mental health Trust).
Audit Commission
The Audit Commission regulates the proper control of public finances by local authorities
and the NHS in England and Wales. The Commission audits NHS Trusts; primary care
Trusts and strategic health authorities to review the quality of their financial systems. It
also publishes independent reports which highlight risks and good practice to improve
the quality of financial management in the health service, and, working with the Care
Quality Commission, undertakes national value-for-money studies. Visit: www.auditcommission.gov.uk/Pages/default.aspx
Benchmark
A standard, or a set of standards, used as a point of reference for evaluating
performance or level of quality.
Board (of Trust)
The role of the Trust’s board is to take corporate responsibility for the organisation’s
strategies and actions. The chair and non-executive directors are lay people drawn from
the local community and are accountable to the Secretary of State. The chief executive is
responsible for ensuring that the board is empowered to govern the organisation and to
deliver its objectives.
Care Quality Commission
The Care Quality Commission (CQC) replaced the Healthcare Commission, Mental
Health Act Commission and the Commission for Social Care Inspection in April 2009.
The CQC is the independent regulator of health and social care in England. It regulates
health and adult social care services, whether provided by the NHS, local authorities,
private companies or voluntary organisations. Visit: www.cqc.org.uk
Care Quality Review Group
A meeting held monthly between UHCW and the Commissioners to discuss clinical
quality issues at the hospital.
Clinical Audit
Clinical audit measures the quality of care and services against agreed standards and
suggests or makes improvements where necessary.
Clinical Coding
Clinical coding translates the medical terminology written by clinicians to describe a
patient’s diagnosis and treatment into standard, recognised codes. The accuracy of
coding is an indicator of the accuracy of the patient’s health record.
Clostridium Difficile
is a species of Gram-positive bacteria that causes severe diarrhoea and other intestinal
disease when competing bacteria in the gut flora have been wiped out by antibiotics.
Commissioners
Commissioners are responsible for ensuring adequate services are available for their
local population by assessing needs and purchasing services. Primary care Trusts are
the key organisations responsible for commissioning healthcare services for their area.
They commission services (including acute care, primary care and mental healthcare)
for the whole of their population, with a view to improving their population’s health.

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Commissioning for Quality and Innovation (CQUIN)
High Quality Care for All included a commitment to make a proportion of
providersâ&#x20AC;&#x2122; income conditional on quality and innovation, through the
Commissioning for Quality and Innovation (CQUIN) payment framework.
Dashboard
A toolset developed to provide help clinicians, with the relevant and timely
information they need to inform daily decisions that improve quality of patient
care. The toolset gives clinicians easy access to the wealth of NHS data that is
being captured locally, in a visual and usable format, whenever they need it. At
its core it will display locally relevant information alongside relevant national
metrics.
Discharge
i) Complex
Concerns patientsâ&#x20AC;&#x2122; who have continuing healthcare needs and may have a
level of social care need requiring specialist equipment to support them in a
community environment
ii) Simple
Concerns patients discharge into the community or home utilising access to
intermediate care services, restarting short term packages of care and
accessing rehabilitation facilitates in the community.
Dr Foster
Is a provider of healthcare information in the United Kingdom, monitoring the
performance of the National Health Service and providing information to the public. It is a
joint-venture with the Department of Health and was launched in February 2006.
Health Act
An Act of Parliament is a law, enforced in all areas of the UK where it is applicable. The
Health Act 2009 received Royal Assent on 12 November 2009.
Healthcare
Healthcare includes all forms of healthcare provided for individuals, whether
relating to physical or mental health, and includes procedures that are similar to
forms of medical or surgical care but are not provided in connection with a medical
condition, for example cosmetic surgery.
High Quality Care for All
High Quality Care for All, published in June 2008, was the final report of the NHS Next
Stage Review, a year-long process led by Lord Darzi, a respected and renowned
surgeon, and around 2000 frontline staff, which involved 60,000 NHS staff, patients,
stakeholders and members of the public.
Information Governance Toolkit
The IG Toolkit is an online system which allows NHS organisations and partners to
assess themselves against Department of Health Information Governance policies and
standards.
Intentional Rounding
This involves reviewing all patients at set intervals for key safety issues e.g.
repositioning, toileting, food, fluid and pain management and has the potential to impact
on reduction of other harms such as pressure ulcers and dehydration.

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Key Performance Indicator (KPI)
A type of performance measurement. KPIs are commonly used by an organisation to
evaluate its success or the success of a particular activity in which it is engaged
Local Involvement Networks (LINks)
Local Involvement Networks (LINks) are made up of individuals and community groups
which work together to improve local services. Their job is to find out what the public like
and dislike about local health and social care. They will then work with the people who
plan and run these services to improve them. This may involve talking directly to
healthcare professionals about a service that is not being offered or suggesting ways in
which an existing service could be made better. LINks also have powers to help with the
tasks and to make sure changes happen.
Major Trauma
Multiple, serious injuries that could result in death or serious disability. These might
include serious head injuries, severe gunshot wounds or road traffic accidents.
MRSA Bacteraemia
Methicillin-resistant Staphylococcus Aureus (MRSA) is a bacterium. MRSA is any strain
of Staphylococcus aureus that has developed resistance to antibiotics.
National Patient Safety Agency (NPSA)
The National Patient Safety Agency is an armâ&#x20AC;&#x2122;s-length body of the Department of Health,
responsible for promoting patient safety wherever the NHS provides care.
National Patient Surveys
The National Patient Survey Programme, coordinated by the Care Quality
Commission, gathers feedback from patients on different aspects of their experience
of recently received care, across a variety of services/settings. Visit:
www.cqc.org.uk/usingcareservices/ healthcare/patientsurveys.cfm
National Research Ethics Service
The National Research Ethics Service is part of the National Patient Safety Agency. It
provides a robust ethical review of clinical trials to protect the safety, dignity and wellbeing of research participants as well as ensure through the delivery of a professional
service that it is also able to promote and facilitate ethical research within the NHS.

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
NCEPOD's purpose is to assist in maintaining and improving standards of medical and
surgical care for the benefit of the public by reviewing the management of patients, by
undertaking confidential surveys and research, and by maintaining and improving the
quality of patient care and by publishing and generally making available the results of
such activities.
Never Event
Never Events are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented.
NHS Choices
A website for the public containing all information on the NHS.

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NHS Next Stage Review
A review led by Lord Darzi. This was primarily a locally led process, with clinical visions
published by each region of the NHS in May 2008 and a national enabling report, High
Quality Care for All, published in June 2008.
NICE - National Institute of Clinical Excellence
NICE is an independent organisation responsible for providing national guidance on
promoting good health and preventing and treating ill health.
NVQ - National Vocational Qualification
Overview and Scrutiny Committees
Since January 2003, every local authority with responsibilities for social services (150
in all) has had the power to scrutinise local health services. Overview and scrutiny
committees take on the role of scrutiny of the NHS – not just major changes but the
ongoing operation and planning of services. They bring democratic accountability into
healthcare decisions and make the NHS more publicly accountable and responsive to
local communities.
Pathway
A tool used by all healthcare professionals in treating patients, in which the different
tasks involved in the patient’s care are defined.
Periodic reviews
Periodic reviews are reviews of health services carried out by the Care Quality
Commission (CQC). The term ‘review’ refers to an assessment of the quality of a
service or the impact of a range of commissioned services, using the information that
the CQC holds about them, including the views of people who use those services.
Pressure Ulcer
Also sometimes known as bedsores or pressure sores, are a type of injury that affects
areas of the skin and underlying tissue. They are caused when the affected area of skin
is placed under too much pressure. Pressure ulcers can range in severity from patches
of discoloured skin to open wounds that expose the underlying bone or muscle.
Avoidable pressure ulcer: The person receiving care developed a pressure
ulcer and the provider of care did not do one of the following: evaluate the person’s
clinical condition and pressure ulcer risk factors; plan and implement interventions that
are consistent with the persons needs and goals, and recognised standards of practice;
monitor and evaluate the impact of the interventions; or revise the interventions as
appropriate.
Unavoidable pressure ulcer: means that the individual developed a pressure
ulcer even though the individual’s condition and pressure ulcer risk had been evaluated;
goals and recognised standards of practice that are consistent with individual needs has
been implemented. The impact of these interventions had been monitored, evaluated
and recorded; and the approaches had revised as appropriate.
o

Inherited pressure ulcer: A patient is admitted to the Trust with pressure damage
and this is identified or becomes apparent within 72 hours of admission

o

Acquired pressure ulcer: the patient develops a pressure ulcer whilst a hospital in
patient after the first 72 hours of admission

o

Grade 1 pressure ulcer: The skin at this point is red and on the application of fingertip pressure the skin remains red.

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o

Grade 2 pressure ulcer: the superficial layer of the skin is damaged. It presents as
a blister, abrasion or shallow crater and any of these can have blue / purple / black
discoloration.

Primary Care Trust
A primary care Trust is an NHS organisation responsible for improving the health of
local people, developing services provided by local GPs and their teams (called primary
care) and making sure that other appropriate health services are in place to meet local
people’s needs.
QIPP Agenda
Quality, Innovation, Productivity and Prevention- QIPP is working at a national, regional
and local level to support clinical teams and NHS organization’s to improve the quality of
care they deliver while making efficiency savings that can be reinvested in the service to
deliver year on year quality improvements.
Registration
From April 2009, every NHS Trust that provides healthcare directly to patients must be
registered with the Care Quality Commission (CQC). In 2009/10, the CQC is registering
Trusts on the basis of their performance in infection control.
Research
Clinical research and clinical trials are an everyday part of the NHS. The people who do
research are mostly the same doctors and other health professionals who treat people.
A clinical trial is a particular type of research that tests one treatment against another. It
may involve either patients or people in good health, or both.
Root Cause Analysis
A structured approach to identifying the factors that resulted in the nature, the magnitude,
the location, and the timing of the harmful outcomes (consequences) of one or more past
events in order to identify what behaviors, actions, inactions, or conditions need to be
changed to prevent recurrence of similar harmful outcomes and to identify the lessons to
be learned to promote the achievement of better consequences.
Secondary Uses Service
The Secondary Uses Service is designed to provide anonymous patient-based data for
purposes other than direct clinical care such as healthcare planning, commissioning,
public health, clinical audit and governance, benchmarking, performance improvement,
medical research and national policy development.
Serious Incident requiring Investigation (SIRI)
A serious incident requiring investigation is defined as an incident that occurred in
relation to NHS-funded services and care resulting in one of the following:
• Unexpected or avoidable death of one or more patients, staff, visitors or members of
the public;
• Serious harm to one or more patients, staff, visitors or members of the public or where
the outcome requires life-saving intervention, major surgical/medical intervention,
permanent harm or will shorten life expectancy or result in prolonged pain or
psychological harm (this includes incidents graded under the NPSA definition of
severe harm);

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• A scenario that prevents or threatens to prevent a provider organisation’s ability to
continue to deliver healthcare services, for example, actual or potential loss of
personal/organisational information, damage to property, reputation or the environment,
or IT failure;
• Allegations of abuse;
• Adverse media coverage or public concern about the organisation or the wider NHS;
• One of the core set of ‘Never Events’ as updated on an annual basis and currently
including:
• Wrong Site Surgery
• Wrong Implant/prosthesis
• Retained foreign object post-operation
• Wrongly prepared high-risk injectable medication
• Maladministration of potassium-containing solutions
• Wrong route administration of chemotherapy
• Wrong route administration of oral/enteral treatment
• Intravenous administration of epidural medication
• Maladministration of Insulin
• Overdose of midazolam during conscious sedation
• Opioid overdose of an opioid-naïve patient
• Inappropriate administration of daily oral methotrexate
• Falls from unrestricted windows
• Entrapment in bedrails
• Transfusion of ABO-incompatible blood components
• Transplantation of ABO or HLA-incompatible organs
• Misplaced naso- or oro-gastric tubes
• Wrong gas administered
• Failure to monitor and respond to oxygen saturation
• Air embolism
• Misidentification of patients
• Severe scalding of patients
• Maternal death due to post partum haemorrhage after elective caesarean
section
Special Review
A special review is a review carried out by the Care Quality Commission (CQC).
Special reviews and studies are projects that look at themes in health and social care.
They focus on services, pathways of care or groups of people. A review will usually
result in assessments by the CQC of local health and social care organisations. A
study will usually result in national-level findings based on the CQC’s research.
Strategic Health Authorities
Strategic Health Authorities (SHAs) were created by the Government in 2002 to
manage the local NHS on behalf of the Secretary of State. SHAs manage the NHS
locally and are a key link between the Department of Health and the NHS
SHAs (there are ten in total) are responsible for:
•

developing plans for improving health services in their local area;

•

making sure that local health services are of a high quality and are performing well;

•

increasing the capacity of local health services – so they can provide more services;
and

•

Making sure those national priorities – for example, programmes for improving cancer
services – are integrated into local health service plans.

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Teaching Trusts
A hospital that is affiliated to a medical school and provides the students with teaching
and supervised practical experience